IS YOUR FACILITY LEAN YET? Cutting Costs, Improving Safety, Quality, & Employee Morale

1. IS YOUR FACILITY LEAN YET?Cutting Costs, Improving Safety, Quality, & Employee Morale Presented by Kathy Pflaum, BBA, St. Francis Health Center, Topeka, KS

2. SESSION OBJECTIVES Participants should be able to define LEAN Participants should be able to define DMAIC Learn how LEAN is applicable to Pharmacy Purchasing

3. LEAN GOAL • Create flow and pull value through the value stream by eliminating operations that do not add value.

4. DO YOU ALREADY HAVE THE WRONG IDEA? • Common misconceptions about LEAN • It is a factory thing - started by Toyota • It will not work here, just another program • It is all about 1 piece flow • 6S is about cleaning up your office and work area • We are different • It is an excuse to take away our jobs

5. WHAT IS LEAN? • A structured method to drive out waste in any process in the health care environment. • Focused on adding value in serving the customer. • Any group of tasks is a process. • Focuses on reducing waste and adding value to improve business metrics.

6. LEAN THINKING • A methodology focused on eliminating waste in the processes from the voice of the customer. • Focus on the rights: • Right Service • Right Amount • Right Place • Right Time • Right Condition

7. ROOM FOR IMPROVEMENT • “The level of waste in U.S. medicine approaches 50%” • Don Berwick, MD, MPP, FRCP – President and CEO • Institute for Healthcare Improvement

8. CAN YOU CHANGE BEHAVIOR? • LEAN is about a way of thinking • How we do the job every day • Improving the processes in the work environment • Value added tasks from the customer expectation • Providing the opportunity to work for delighted customers • Reducing MUDA – Japanese term for activity that is wasteful and does not ad value from the customers perspective

9. DEFINING VALUE ADDED TASKS • How do you know? • KEEP – Value Added Activities • MINIMIZE – Non-value added but necessary to complete the task or treatment • ELIMINATE – Non-value added MUDA ALL DEFINITION OF VALUE ADDED TASKS MUST BE FROM THE VOICE OF THE CUSTOMER.

10. METHODOLOGY - DMAIC • DEFINE • MEASURE • ANALYZE • IMPROVE • CONTROL

11. METHODOLOGY - DEFINE • Define who the customers are in the process • What are the customer’s requirements and expectations? • Where is the starting point and ending point of the project • Know what the current process is by mapping the process flow.

12. METHODOLOGY - MEASURE • What is the customer demand? • Develop a data collection plan for the product or process • Create a Value Stream Map

13. METHODOLOGY - ANALYZE • What is the difference between the current performance and the goal performance? • Prioritize improvement opportunities • Look for MUDA at every turn • Ask WHY, WHY, WHY, WHY, WHY

14. METHODOLOGY - IMPROVE • Create world class solutions • Develop and implement improvement plans • 6S is a fast way to improve with a KAIZON event.

15. METHODOLOGY - CONTROL • Prevent going backward to the way “we have always done it” • Develop a monitoring plan • Make the new process a habit for the institution • Celebrate your success

16. DEFINE WITH A CHARTER • Develop a Charter – an agreement between management and the team about expectations. • The Charter is a dynamic document, meant to be changed. • Elements of the Charter • Business Case – Why do this project and expected benefits • Problem & Aim Statements • Project Scope - Set boundaries • Measureable Goal – VOICE OF THE CUSTOMER LINK • Financial Benefits – Soft or Hard Green dollars

17. CENTRAL SUPPLY CASE STUDY – Building the Charter • BUSINESS CASE - Change PARs on the 5th floor in both supply rooms to meet the demands of the customer and reduce inventory dollars by 40%. • PROBLEM STATEMENT - Both supply rooms on 5th floor have items stocked in abundance of the need of the customer, thus having excess inventory dollars tied up in unnecessary stock. • AIM STATEMENT - Increase/decrease PARs on 5th floor supply rooms to meet the needs of the Nursing Staff and reduce inventory stocked in the supply rooms by 40%.

18. CASE STUDY – Building the Charter • PROJECT SCOPE START: Collect data about usage and current PARs from the Lawson system. END: Changing of PARs and reducing the inventory on hand in the supply rooms. • MEASURABLE GOAL CTQ: Have the supplies in the supply room when the Nursing Staff needs them. GOAL: Reduce inventory by 40% • FINANCIAL BENEFITS - Reduction of inventory. Increased supply turns Increased ROI

19. CASE STUDY – Building the Charter • PROJECT PLAN - Milestones Data Analysis of 6th floor supply inventory and data Compiled 7/14/2009 Recommended PARs reviewed by 6th floor Nursing Services completed 7/21/2009 Charter review done with Champion 5/18/2009 PARs changed to agreed upon #’s and guns uploaded for inventory 8/4/2009 • RESOURCES and ROLES - Lawson reports 5th floor Nursing Services and SPD – Lisa Dunn

20. DEFINE – LEAN DELIVERABLES • Evaluate the Voice of the Customer (VOC) • Describe the needs and the perceptions of the product or service from the customer perspective. • Validate the hypothesis of customer need • Listen to the customer by asking open ended questions • Central Supply Project • Our customers were as follows: Nurses, Patients, Aides, Family & Friends of Patient

21. DEFINE – MAP THE PROCESS • SIPOC • Suppliers • Inputs • Process • Outputs • Customer

22. CENTRAL SUPPLY CASE STUDY - SIPOC INPUT ORDERS OUTPUT CUSTOMER SUPPLIER Discovery of need Order Phone Computer Baxter Lawson Place Order WAIT Apology To Patient Delivered Walk In Right Item Delivered Wrong Item Delivered

23. DEFINE – PLAN THE PROJECT • Get an ARMI • A = Approval of team decisions – the sponsor or champion • R = Resource to the team • M = Member of the team • I = Interested party

24. DEFINE – WHAT MARKS SUCCESS? • Do you have a focused project? • Is it relevant to your business? • Is your methodology sound? • Can you execute? • Do you have the right ARMI?

25. MEASURE – WHY? • Without measurement capabilities how do you know if you improved the process? • Data allows for us to remember all situations. Customers tend to remember the extremes. • Without data, there is no base line

26. WHAT IS A GOOD MEASURE? • Measurement is reflective of the VOC. • Measurement is tied to business goals • Identified improvement opportunities can be measured • Can be measured consistently over time

27. Data vs. Tribal Knowledge You don’t need data. . .I can tell you what the problem is! A customer remembers the extremes – what impacts them (today). Data allow us to remember all situations, and presents an objective picture of the process.

28. VOICE OF THE CUSTOMER • Do you know who the customer is? • Do you know what the customer wants? Do you really know? • Are you listening?

29. CENTRAL SUPPLY CASE STUDY • Identified customers were: • Nursing Services • Patients • Physicians • SPD • Other Departments such as Pharmacy, EVS • Clinics • Hospital in general

30. MEASURE – TYPES OF DATA • Continuous Data • Measures of time, dollars, etc. • Cost per test, product utilization per billable unit • Discrete Data • Counts of defects • Number of corrected test reports, number of OSHA incidents

31. WHAT IS VARIBLE DATA? • Time • Money • Scaled Measurement (I.e. length, height, weight, temperature) • Can have decimals or fractions • Throughput (volume of work accomplished)

32. VARIBLE DATA • Examples of Variables Data: • Waiting Time • Cost per case for a DRG • Daily patient weight • Monthly accounts receivable • Volume of prescriptions filled

33. WHAT IS ATTRIBUTE DATA? • Discrete-whole numbers-not measures • (Original data can’t be a fraction or scaled data) • Two kinds of attributes data: • Count..1,2,3,4,etc. (Defects) • Classification..either-or data (good/bad, pass/fail, yes/no) (Defectives)

34. ATTRIBUTE DATA • Examples of Attribute Data: • # falls per # of patient days this month • # medication errors per 1000 doses • proportion of diabetic patients who smoke • proportion of patients who died (mortality)

35. CENTRAL SUPPLY PROJECT

36. WORST OFFENDERS FOR PHONE OR WALK IN ORDERS

37. ANALYZE – WHERE IS THE WASTE? • 8 Types of waste • Defects • Overproduction • Transportation • Waiting • Inventory • Motion • Processing • Intellect

38. ANALYZE – STANDARD WORK • Standard work allows the process to be high quality on a reliable and sustained basis. • The objective is to clearly communicate exactly how the job should be performed. • It optimizes the work flow in the best known sequence and utilizes the most effective combination of • People • Materials • Methods • Machines

39. 5 Whys • WHY does this problem happen? • Backup operators take longer to connect callers. • Focused Problem • Customers complain about waiting too long to get connected to staff during lunch hours. • WHY does it take backup operators longer? • Backup operators don’t know the job as well as the regular operators do. • WHY don’t the backup operators know the job as well? • There is no special training, no job aids to make up for the gap in experience, or on-the-job learning for the backup operators. • WHY don’t they have special training or job aids? • In the past, the organization has not recognized this need. • WHY hasn’t the organization recognized this need? • The organization has no system to identify training needs.

40. UNNECESSARY INVENTORY COMMUNICATION CONSISTENCY DELIVERY Communication of MFG backorders Incorrect Item EMERGENT NEED EDUCATION ORDERING

41. QUICK HITS – A PHARMCY FAVORITE • Quick hits are rapid Improvement Opportunities • If there is any doubt about doing it validate before proceeding. JUSTDOIT !

42. PHARMACY OPPORTUNITY

43. IMPROVE – BRAINSTORMING • Generating solutions – ask the people who do the job • Brainstorming to be successful • Do not judge ideas, let them flow out • Encourage “far-out” ideas • Hitchhiking on others ideas is encouraged

44. CENTRAL SUPPLY CASE STUDY - IMPROVE • After brainstorming, it was decided that the PAR reduction would be a quick hit. • An additional Charter was written to define, analyze, measure, improve and control the ordering process • Templates were built for each nursing unit with their specific needs on the template • Training on using Lawson to order was conducted. • Expectations were set for ordering all items through Lawson versus call ins and walk-ins.

45. IMPROVE – 6S • SORT – Keep only what is required • STORE – Arrange and identify for ease of use • SHINE – Clean • STANDARDIZE – Eliminate causes to reduce variation • SUSTAIN – Discipline, a plan, a schedule – stick to it!! • SAFETY

46. IMPROVE – 6S BENEFITS • Opportunity for creative input. • Pleasing work area. • Increased job satisfaction. • Removes obstacles and frustrations in a constructive setting. • Organizes work load. • Clearer communication

47. CONTROL – IT IS EASY TO REVERT • Provides a method to continue to monitor the improvement. • Effectively maintaining means: • Verify the results for at least 12 months • Document the new methods in a way that people will understand and use. • Make regular course corrections. • Share the information learned with co-workers. • Think about what is the next improvement.

48. CONTROL – REPORT THE RESULTS • Keep it simple! • Document the learning's from the project. • Results • Work process • Team’s process • Share with the organization

49. OTHER LEAN PHARMACY PROJECTS • Vaccines for Children implementation • IV Waste project • Revenue Charging Changes for the Health Center • Revenue Charging Changes for the clinics • Hazardous Pharmaceutical Waste • Dietary Procurement • Cancer Medication treatment cost tables

50. CELEBRATE!! THANK YOU QUESTIONS??