Using Toyota Lean Principals

to
Improve Inpatient Flow Process

May 18, 2009

Improving Inpatient Flow

Barbara Versage RN, MSN, MBA

System for Partners in Performance Improvement
Lehigh Valley Health Network
Lean Consultant

Barbara Versage has no relevant financial relationships or affiliations to disclose in regard to the content of this
presentation.
 Presentation Objectives
1) Application of Toyota Production System (TPS)
concepts to Improve Inpatient Flow
2) Using Value Stream Analysis to ensure cross-
functional department performance
3) Identify a measurement matrix used to
determine the success of applying lean in
hospital flow.
 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use pull systems
4) Level out the workload
5) Build a culture of stopping to fix problems
6) Standardize tasks
7) Use visual control
8) Use only reliable well tested technology
 14 Toyota Way Principals
III. Add Value to the Organization by Developing
Your People and Partners
9) Grow leaders who understand and use the concepts
10) Develop exceptional people and teams who follow your
philosophies
11) Respect your extended network of supplies and partners

IV. Continuously Solving Root Problem Drives

Organizational Learning
12) Go and see for yourself to thoroughly understand
13) Make decisions slowly by consensus; implement rapidly
14) Learn through continuous improvement & reflection
 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use pull systems
4) Level out the workload
5) Build a culture of stopping to fix problems
6) Standardize tasks
7) Use visual control
8) Use only reliable well tested technology
“The Times They Are Changing”
……….Bob Dylan

§ Decreasing reimbursement
§ Increasing uncompensated care
§ Increased cost of capital
§ Medical Tourism
§ Consumer Expectation
The patient…
 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use pull systems
4) Level out the workload
5) Build a culture of stopping to fix problems
6) Standardize tasks
7) Use visual control
8) Use only reliable well tested technology
 Department
Activity Unit
Department
Activity Unit
Value Stream

Department
Activity Unit
VALUE STREAM
Department
Activity Unit
Department
Activity Unit
Department
Activity Unit
 DISCHARGE
CONSULTS –
PHYSICAL THERAPY PHYSICIAN
Value Stream

SUPPLIES & EQUIPMENT

VALUE STREAM
COLLOBORATIVE ROUNDS
LAB & HEART STATION
ADMISSION
 Value Adding Work
Value
Adding

Arrive Leave
90 % NVA 10%

Total Flow Time for Patient

30%-40% of Health care costs are due to waste.

Education for Lean Healthcare Institute

 8 Wastes in Healthcare: “U-WIT-D-MOP”
Unused Human Potential: Untapped creativity/talent/injuries

Waiting: patients/providers/material

Inventory: stacks of work/piles of supplies

T ransportation: transporting people, paperwork

Defects: wrong information/rework

M otion: finding information/double entry/searching

Overproduction: duplication/extra information

Processing: extra steps/checks/workarounds

Process
Map
Communication Circle
Spaghetti
Diagram
 Time Study
Misc
Prep

Test

Wait
 8 Wastes in Healthcare: “U-WIT-D-MOP”
Unused Human Potential: Untapped creativity/talent/injuries

Waiting: patients/providers/material

Inventory: stacks of work/piles of supplies

T ransportation: transporting people, paperwork

Defects: wrong information/rework

M otion: finding information/double entry/searching

Overproduction: duplication/extra information

Processing: extra steps/checks/workarounds

 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use visual control
4) Level out the workload
5) Use pull system
6) Standardize tasks
7) Build a culture of stopping to fix problems
8) Use only reliable well tested technology
Where is your stuff?
6S
§ Sort
§ Remove items not needed daily (red-tag process)

§ Set in Order
§ Label items and make it obvious where they belong

§ Shine/Sweep
§ Clean and inspect everything, inside and out
§ Visually sweep area to make sure everything is in its place

§ Safety
§ Required safety information is posted
§ Exits and emergency equipment are clearly marked and functional

§ Standardize
§ Establish policies and Standard Work to ensure 6S

§ Sustain
§ Training, discipline, daily activities, self-audits
 Total Calls from 5K
to SDS for Supplies
90

80

70

60
# of Calls

50

40

30

20

10

0
8/4 8/18 9/1 9/15 9/29 10/13
5K – Staff Satisfaction with changes

4.8
Equipment Room 1 -------------------------------- 5
4.0
Supply Room 1 -------------------------------- 5
 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use visual control
4) Level out the workload
5) Use pull system
6) Standardize tasks
7) Build a culture of stopping to fix problems
8) Use only reliable well tested technology
 Discharge Work Load

7
6
5
# of Tasks

4 Before
3 After
2
1
0
Day Shift Evening Night Shift Provider Case
RN Shift RN RN Manager
Pa
tie

0
5
10
15
20
25
30
35
40
Pa nt #
tie 14
n
Pa t #1
tie 3
Pa nt #
tie 1
Pa nt #
t 8
Pa ient
tie #2
n
Pa t #1
ti 0
Pa ent
tie #9
n
Pa t #1
tie 2
Pa nt #
t 6
Pa ient
tie #7
n
Pa t #1
ti 5
Pa ent
tie #4
n
Pa t #1
Random Weekday Sample

tie 1
Pa nt #
Order to Results Available - Echo

ti 3
Pa ent
tie #5
nt
#1
6
Random Reading – unsure of when tests available

Hrs
 Complete to Results Available
Heart Station Readings-
40
Load Level
35 14
30 12

25 10
Hours

Hours
8
20
6
15
4
10
2
5 0
0 #1 #4 #7 #10 #13 #16 #19 #22 #25
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16
Patients
Patient Number
 14 Toyota Way Principals
I. Long Term Philosophies
1) Base decisions on long term philosophies

II. Right Process Produce Right Results

2) Create continuous flow
3) Use visual control
4) Level out the workload
5) Use pull system
6) Standardize tasks
7) Build a culture of stopping to fix problems
8) Use only reliable well tested technology
 Standard Work

§ Defines the most efficient way to perform

that task

§ Is known and followed by all who perform

that task

§ Is the basis for all continuous improvement

 14 Toyota Way Principals
II. Right Process Produce Right Results
7) Build a culture of stopping to fix problems
8) Use only reliable well tested technology

III. Add Value to the Organization by Developing Your People

and Partners
9) Grow leaders who understand and use the concepts
10) Develop exceptional people and teams who follow your philosophies
11) Respect your extended network of supplies and partners

IV. Continuously Solving Root Problem Drives Organizational

Learning
12) Go and see for yourself to thoroughly understand
13) Make decisions slowly by consensus; implement rapidly
14) Learn through continuous improvement & reflection
 Objectives Summary
1) Application of Toyota Production System (TPS)
concepts to Improve Inpatient Flow
2) Using Value Stream Analysis to ensure cross-
functional department performance
3) Identify a measurement matrix used to
determine the success of applying lean in
hospital flow.
 References:
§ Liker, Jeffrey, The Toyota Way. McGraw-Hill Publishers,
Madison, WI 2004.
§ Maskell, Brian and Baggaley, Bruce. Lean Accounting:
What’s It All About? Association for Manufacturing
Excellence's, Target Magazine. September 2006.
http://www.leanaccountingsummit.com/LeanAccountingD
efined-Target.pdf
§ Johnson, H.Thomas, Lean Dilemma: Choose System
Proncipals or Management Accounting Controls, Not
Both, September 2006
http://www.in2in.org/insights/TomJohnson-
LeanDilemma.pdf