crafting a system-wide lean effort what does work; what does not
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Crafting a System -wide Lean Effort: What Does
Work; What Does Not
Robert W. Pryor , M.D., Chief Operating Officer and Chief Medical Officer
Scott and White Healthcare System
with Steve Hoeft , Lean Six Sigma DirectorAltarum Institute
Robert (Bob) Pryor, M.D., M.B.A., C.P.E., F.A.A.P., F.C.C.M., F.C.C.P.
• Certified in Lean Healthcare from the University of Michigan, College of Engineering, Center for Professional Development
• Presently Chief Medical Officer/Chief Operating Officer, Scott & White Healthcare, Temple, TX
• Previously Chief Medical Officer at St. Joseph’s Hospital & Medical Center, Phoenix, AZ
• Board Certified by the American Board of Pediatrics
• Fellow of the American College of Chest Physicians and The American College of Critical Care Medicine
• Graduate of Baylor University in Waco, TX and Medical Degree from The University of Texas Medical Branch at Galveston, TX
• MBA from the Arizona State University
• Member of the American College of Physician Executives
• Widely published
Steve Hoeft: Bio
Lean!
� 26 years of experience: Engineering, production, Lean, quality, continuous improvement efforts; plus facility design, simulation and scheduling
� Delta (Kogyo) USA – lean supplier to Mazda (Sensei: Joe Shimada)� Johnson Controls – developed internal Lean Office:
• Studied lean principles directly from Toyota in KY (with Sensei)• Co-authored JCI Manufacturing System (ASTD Award winner)
� Lean Enterprise coach/consultant (8 years):• Personally led 300+ Lean events; developed hundreds of successful Lean Facilitators• Helped establish Value Stream Visions with firms in many industries
� Presently: Altarum Institute (since Feb 2003):• Lean Six Sigma for Healthcare: UMass, Scott & White, Memorial Sloan-Kettering
Cancer Center, William Beaumont, University of Michigan Healthcare System, St. John's (IL) and the entire Hospital Sisters Health System, Blue Cross Blue Shield, Henry Ford Health System, Univ. Health System-San Antonio, Yale New Haven Health, Ontario Health Quality Council, Vancouver Coastal, Kaiser Permanente, Tri-City Medical Center, Lakewood Health System, hospitals in Singapore, and others
• Major Government transformation projects: OSD, Air Force-wide, Repair & Base Ops, Lean Purchasing-PSCM, Veteran's Health Administration (VHA), AF Surgeon General
� Principal Instructor for the University of Michigan’s Lean Manufacturing, New Product Design and Healthcare Certificate programs
What Do We Mean By “Works” ?
• Culture shift
• Critical mass of Leaders and staff “think” differently
• Staff that prevent problems or solve them as they arise; not by reactive, time-consuming work-arounds
– Staff bring problem, analysis and actions (A3 Thinking)
• Internal capacity for self sufficiency
• Year over year sustainment of changes/results
B4
Purpose
5
Agenda
• Who is Scott & White?
• 5 Questions as we deployed Lean “from scratch”
• Demonstration of Hansei (Reflection); tips
• Benefits and Challenges of being a “system”
• How to (or Not to) Spread standards to other sites
6
Scott & White Healthcare
Vision: “Most Trusted and Most Valued Name in
American Healthcare”
Scott &White Healthcare33 Primary Clinic Locations
Mason
ErathHood
Somervell
Johnson
HillBosque
HamiltonMills
San Saba
Llano
Hays
Blanco
McLennan
CoryellLeon
Robertson
FallsBell
Burnet
Travis
Williamson
Caldwell
Milam
Bastrop
Lee
Burleson
Brazos
Madison
Walker
Grimes
Washington
Austin
Waller
Lampasas
1. Bellmead2. Belton3. Burnet4. Cedar Park5. Cedar Park West6. College Station7. Gatesville8. Georgetown9. Georgetown Central10. Harker Heights11. Hewitt12. Horseshoe Bay13. Hutto14. Killeen15. Killeen West16.Kingsland17.Llano
18. Marble Falls19. Mason20. Moody21. Northside22. Pflugerville23. Salado 24. San Saba25. Santa Fe Family Med.26. Taylor27. Temple28. Temple Towne Center
Pediatrics 29. S&W Round Rock30. Waco31. Wells Branch32. Belton Pedi Clinic33. Hillcrest Pedi Clinic
8
Scott &White Healthcare24 SpecialtyClinic Locations
Mason
ErathHood
Somervell
Johnson
HillBosque
HamiltonMills
San Saba
Llano
Hays
Blanco
McLennan
CoryellLeon
Robertson
FallsBell
Burnet
Travis
Williamson
Caldwell
Milam
Bastrop
Lee
Burleson
Brazos
Madison
Walker
Grimes
Washington
Austin
Waller
Lampasas
Primary Clinic
Specialty Clinic
1. Cosmetic Surgery Center – B/CS2. Sports Therapy and Rehabilitation Center – Hewitt3. Killeen Cancer Center4. Killeen Dialysis Center5. Killeen Dialysis West6. Killeen Ob/Gyn Clinic7. S&W Cardiology at Metroplex8. S&W Gastroenterology at Metroplex 9. S&W Orthopedic Services at Metroplex10. S&W Urology Services at Metroplex11. Round Rock Cosmetic Surgery Center12. Round Rock Dialysis Clinic13. Ambulatory Pediatric Clinic – Temple14. Center for Diagnostic Medicine – Temple15. Dermatology Clinic – Temple16. Mental Health Center – Temple17. Cosmetic Surgery Center – Temple18. S&W Pavilion – Temple19. Santa Fe Center – Temple20. Watson Wise Dialysis Center – Temple21. Ob/Gyn – Waco22. Health Express – Temple23. Pediatric Urgent Care Clinic – Temple24. Georgetown Sports Medicine Clinic
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Scott &White Healthcare
10 HospitalLocations
1. Scott & White Memorial Hospital – Temple2. Continuing Care Hospital – Temple3. Scott & White Healthcare – Round Rock4. Coryell Memorial Hospital – Gatesville5. Metroplex Hospital – Killeen6. Rollins Brook Hospital – Lampasas7. Hillcrest Hospital – Waco8. Llano Hospital – Llano9. King’s Daughters – Temple 10.Proposed Lake of the Hills Hospital –
Marble Falls
Primary Clinic
Specialty Clinic
Hospital
Mason
ErathHood
Somervell
Johnson
HillBosque
HamiltonMills
San Saba
Llano
Hays
Blanco
McLennan
CoryellLeon
Robertson
FallsBell
Burnet
Travis
Williamson
Caldwell
Milam
Bastrop
Lee
Burleson
Brazos
Madison
Walker
Grimes
Washington
Austin
Waller
Lampasas
10
Becoming a Multi-site System: Timeline View
11
1897
1904
1908
19221923
1949
1963
1977
1979
1997
2000
Scott & White Clinic founded
Temple Sanitarium opens
Electric Cautery experimental
Hospital is renamed Scott & White Hospital Dr. Scott recognized as discoverer of electric cautery
S&W Hospital chartered as not-for-profit organization
Hospital relocates to current location
Texas A&M Medical School opens on S&W campus
S&W Health Plan created
S&W adds 18th satellite clinic; still 1 Hospital
S&W Hospital and S&W Clinics integrated
1978 First “satellite clinic” open in Moody in 1978
2010 Named “Top 100 Hospitals” – 7 th year in a row!
1920 AMA approves Scott & White as teaching hospital-first in TX
1940 Scott & White trained 112 Interns and 20 Resident Physicians
Innovation
2005
2006
20082008
Bob Pryor returns as CMO (Dec)
Built Center for Advanced Medicine (Feb)
Partnership w/ Metroplex Hospital-Killeen
Partnership w/ Rollings Brook Hospital-Lampasas
2010 Today: 10 Hospitals; Numerous Clinics
2006 Built Round Rock Multi-Specialty Clinic
2007 Built Continuing Care Hospital-Temple (May)2007 Built Round Rock Hospital
2010 MOU: John’s Comm’y Hospital-Taylor2010 MOU: Trinity Hospital-Brenham
2010 Acquired Llano Hospital2010 Hospital in planning: Lake of Hills-Marble Falls
2009 Acquired Hillcrest Hospital-Waco (Apr)2009 Acquired Kings Daughters Hospital (Apr)
to be converted to Children’s Hospital
Acceleration!
2010 Hospital in planning: Bryan-College Station
2005 Converted from staff-model HMO to all-payors
2010+ Healthcare Reform; lower reimbursements,35M more people need care, fewer MD’s…2005
Scott &White HealthcareJuly 21, 2009 Conference in DC: “How Do They Do That? Low-Cost, High-Quality Health Care in America.”Leaders were brought to Washington, D.C., by national health care improvement experts to describe their efforts to reduce medical costs in 10 communities where they work.
Dr. Nancy Nielsen of Buffalo, past president of the AMA, characterized as “some Utopian land” the compact between managers and physicians at the Scott & White Clinic . She asked how it would be possible to take “this culture” that had developed and form similar organizations across the United States. “I have to tell you,” she said, speaking colloquially, “this ain’t where it is at in other places.”
Health Affairs Blog, July 28, 2009, “Low-Cost, High-Quality Care In America”
Scott & White leaders invited to D.C.
Scott & White – Keeping Healthcare AffordablePrice-adjusted per-capita Medicare spending
$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)
Not Populated
Everett, WA
Sacramento,CA
Temple, TXTalla-hassee,
FL
La Crosse,WI Cedar
Rapids, IA Sayre,PA
Portland, ME
Richmond, VA
Asheville, NC
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Why Change?
Why Altarum Institute?
• Not for Profit (matched our values)
• Expertise in leading and teaching
• Works with your staff to transfer knowledge and skills and then leave; gives us their materials and tools
• Flexible – can provide more or less support as required
• A learning organization – adapts to create our “model”
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Hansei
“Those who cannot remember the past are condemned to repeat it”
George Santayana
Definition: reflection, reconsideration, introspection.
(Toyota) The conscious individual and group reflection required to learn from episodic activities.
•Note: Very few organizations do this well• Note: Effective organizations do this well
Hansei
15S
How Common is Lean in Healthcare?
ASQ study of 77 hospitals :* 53% of hospitals report some level ("minor," "moderate" or "full") of Lean deployment* 42 percent report some level of Six Sigma deployment* Few hospitals reported "full deployment" of Lean (4 percent)
In order for Lean management to truly be effective, all staff need to believe and act Lean. * 59% lack resources* 41% lack information* 30% lack leadership buy-in* 11% are not familiar with either method
Hospitals Embracing Lean and Six Sigma Strategies, March 24, 2009, Richard Pizzi, Editor, Healthcare Finance News.
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5 Reasons Why Hospitals Struggle With
ALL Change Efforts
Only 4% of hospitals reported "full
deployment" of Lean
1. Why Change?
B17
The Clinic Appointment• Patient calls central S&W phone number• Operator transfers call to a clinic (at random); Clinic transfers calls to
appropriate clinic; put on hold – recorder says to leave a message• Clerk calls Patient back; sometimes reaches them• If reached, Clerk searches for open appointment; can’t find one; says,
“we will send you an appointment by mail”• {4-5 days} Appointment arrives; Patient is unavailable at that time• Patient calls central S&W phone number; finally reserves appt.• Patient arrives for the visit, checks in, sits in waiting room• Patient is called into the exam room, waits for doctor• Doctor diagnoses a URI, and BP is worse• Doctor prints antibiotic prescription, walks all the way to the only
printer (staffroom); upon return, patient says.”I’m allergic to that drug.”• Doctor says to return in a week to check the BP problem• Medical assistant does an EKG• At check out, patient asks the cost; Clerk says. “we’ll bill you”• No appointment is available next week• Upon reaching Pharmacy, clerk says, “Your insurance requires a
generic drug.”• Is there a problem here?
Reflection
• What We Learned (Do, Don’t):
1. Why Change?
S19
5 Reasons Why Hospitals Struggle With
ALL Change Efforts
2. Why TPS/Lean?
B20
Reflection
• It works very well! (creativity over capital)• Lean requires very little specialized training• Lean can be deployed in any process, any type of
organization and at all levels• Lean has an infectious quality, usually with quick, visible
results that cause natural replication• Like medicine, Lean is “learned by doing” (culture shift)• …
2. Why TPS/Lean?
21
5 Reasons Why Hospitals Struggle With
ALL Change Efforts
3. How Long; How Much?
B22
Reflection
• What We Learned (Do, Don’t):
3. How Long/How Much?
S23
5 Reasons Why Hospitals Struggle With
ALL Change Efforts
4. All Staff & LeadersThink and Believe
Lean?
“In order for Lean to truly be effective, all staff need to believe and act Lean”
S24
Reflection
• What We Learned (Do, Don’t):
4. All Staff/Leaders Believe?
5 Reasons Why Hospitals Struggle With
ALL Change Efforts
5. What Resources?
“59% lack resources”
S26
Central vs. Embedded Coaches; CLIP Office; Training ; Roles & Responsibilities
Reflection
• What We Learned (Do, Don’t):
5. What Resources?
27
Some Lean Successes
(Site 1: Temple Campus)
S28
Teams Do Things Right:
Leaders Do the Right Things
Steering Committee
29
Key Steps: •“Go See”; observe; understand programming criteria and forecasts (demand, fte’s, etc.)•Review current OR process and waste •Analyze support and adjacent department impacts on OR•Develop SIPOC for general OR process•Review the 7 Flows – Spaghetti diagrams•Review current/expanded floorspace; revisions•Benchmark other OR’s (Pavilion)•Apply Lean to OR Value Streams/support processes (1 year)
• In advance of final layout for 36 new OR’s, conducted a Lean Layout design review for greatly improved flow
• 24 Current OR’s at Temple were undersized and underperforming• As designed, new SSB layout would not have produced even half
of their expected results• Lounges and other non-value-added space was larger than OR’s• Clean corridor/staging area was too narrow/small; hindered flow• New PACU area appeared to be an unexpected bottleneck• Changes were needed and were caught before ground-breaking• Designs were delayed until the current OR processes were
improved, understood, and a lean design was developed (1 year)Goals:• Improve overall flow• Reduce non-value added space• Improve utilization
Case for Action What We Did
Expectations/Results
Unique
Application
Lean Layout : Surgical Suites Building (Study)
• (Est.) $100M+ saved in new lean-designed SSB• Improved current processes and flow, made some
current OR’s larger, staging wider, lounges smaller• “New” SSB: get 12 more fully functional OR’s!• Building 16 new rooms (vs. 36 new), renovating
16, and leaving 4 alone (total: 36)• Whole project done in 4 years (vs. 6)• Utilization will improve from 50% to (est.) 75%• 70 Proc’s/day up to (est.) 110 (57% ����)
Turning c runch, c hase, c haos to Flow…
• First Cases do not start on time• Key information not available timely • Preference Cards (DPC) not updated/accurate, delays
Goals:Increase number of on time First time startsDecrease missing elementsUpdate DPC cards
Process Owners:Donna, NursingHeather, Nursing
Pre-OR Flow -1: Decision to Incision (VSM)What We DidCase for Action
First time on time starts (before): 33%
First time on time starts (after): 65%
Increased first time starts by32%
Missing elements (before): 156
Missing elements (after): 100
Reduced missing elements by36%
DPC Cards (before): 5538DPC Cards (current): 3260
Reduced DPC cards by 41% (1000’s updated)Neuro service reduce active cards from 182 to 28 … 85% reduction
Gu service reduced active cards from 257 to 60 … 77% reduction
Transplant service reduced cards from 78 to 12 … 85% reduction
Expectations/Results Team
• VSM Plan; worked the Plan• Created Pareto charts on delays by reason• Initiated “Director’s Cup” and “Free Ruth” campaigns as
fun ways for carrot/stick• Incorporate WHO Checklist into standard work• Continue to update and combine DPC cards (Librarian)• Order Scan time from 20 min to 1 min• “One stop shop” layout• 100 % compliant AAU call-ahead for H&P and Consents• Improved marking of patient in Day Surgery• Eliminated paper charts
• Robert, M.D.• Jack, M.D.• Andrea, DaySurgery• Ruth, HUC• Michael, Analyst• Selena, PSEU RN• Mark, IT Specialist• Rosemary, Surgical Tech• Jacqueline, Periop. Support Tech• Jessica, OR Nurse• Gerry, Supply Chain• Carole, OR Scheduler
• Chris, Instrument Processing• Lindsey, Admissions Office • Jo Ann, Embedded Coach• Scott, M.D., Surgery• Debra, Clin. Surgery Scheduler• Darla, M.D., PSEU Provider• Sheila, RN Ortho Clinic• Paula, Patient Rep• Sunnita, M.D., Hospitalist • Katen, M.D., Hospitalist
12
Layout
• Nurses leave the room too many times • Searching for items outside of the room takes too much time• Takes too long to turn the room
Goals:• Decrease number of times the nurse leaves the OR
during a case• Eliminate the need to search for missing items (5S) • Decrease the time it takes to turn over the room
Process Owners:Brandi, NursingMissi, Nursing Education
OR Flow -2: Wheels-in to Wheels-out (Kaizen)What We Did
Team
Case for Action
Nurses leaving room before: __
Nurses/Circulators leave room after: TBD
Room turn beforeOR #3 … avg 26 minOR #17 … avg 42 min
Room turn afterOR #3 … avg 20 min 38%OR #17 … avg 30 min 40%
Expectations/Results
• Log times and reason nurse/circulator leaves room• Two 2-day Kaizen events: observe room turn, reduce
waste, and then “trystorm” improvements• Room turns have improved by 40% during pilots• Results Boards deployed; huddles daily
Next Steps:• Work with OR Team 1 on DPC card corrections to
decrease number of times staff leave OR • 5S OR 17 as a pilot for all OR rooms• Formalize room turn scripts and spread practice to all
OR’s beyond pilot
Roy, MDHarry, MDTheodore, MDGary, MDThomas, CRNAAdam, RadiologyEric, PSTJeanna, Cent. ProcessingSteve, Dispensing ClerkSharon, OR NurseRuby, Surgical Tech.Michael, OR AnalystMissi, Periop. Nursing Coord.
Teresa, Anesthesia Tech.Alisa, Director of NursingAshley, PSSVasillos, M.D.Kevin, PharmacistTheresa, Hem/Onc Assoc. Dir.Brandi, Periop. Nursing Coord.
• Delays in Med Admin• Potential for medication errors
Goals:Decrease Armband OverridesDecrease Medication Overrides
Process Owners:David Jones, Pharmacy Theresa Prather, Nursing
Medication Administration (VSM)What We Did
• Sabine, Coord. Hlth Unit CAM 8N• Judy, Clinical Ed. II• Melody, RN• Amy • David, Hosp. Pharmacy Svs• Carla, RN STC 1• Wayne, Mngr, IS Proj. I• Calvinette, Dir., Nursing• Kendra, Clinical Ed. I• Nabia, Resident Ed Admin.• Trenton, Charge Nurse CCH
Case for Action
Monthly medication overrides (before): 2951
January medication overrides (after): 1702
Reduced Medication Overrides by 42%
Monthly armband overrides (before): 877
January armband overrides (after): 238
Reduced Armband Overrides by 73%
Most common antibiotics now stored on the floor allowing for patients to start therapy more quickly
• Marla, Pharmacy• John, Internal Med Res.• Dianne, Clinical Ed. III/CNS• Julianne, Quality Improvement• Stacy, Mgr., Resp. Care• June, Clinical Ed. II PICU
Expectations/Results Team
• Reduced stock outs in Pyxis machines• Trialed new bar-code scanners; deployed best one• Used arm bands whose bar-codes do not “wash off”• Cleaned up PAR room (5-S) and created space to
add piggyback Pyxis for antibiotics
Next Steps:• Spread lessons learned/best practices to other floors• Add computer with articulating arms in the room to
allow nurses to chart in room
• No standard work for Couriers; duplication of efforts• Security is called to deliver items• Takes too long at locations
Goals:� Create standard drop locations with visual cues� Reduce amount of time security spends delivering items� Consolidate stops for couriers
Process Owners:Frank, Supply Chain
Courier Routes: Materials Transportation (mini-kaizen)What We DidCase for Action
Created visual management to eliminate unclear mail drops - pick up or drop off?
Courier 1 -number of stops (before): 18number of stops (after): 8Reduced stops by: 44%
Courier 2 -number of stops (before): 30number of stops (after): 9Reduced stops by: 30%
Created rules for using Security staff as a STAT courierReduced use of security by 50%
Expectations/Results Team
• Assigned team members to ride with couriers• Used spaghetti diagrams to show flow of materials • Met with management to discuss issues and get buy in• Evaluated who does what and why
Next Steps:• Review number of independent courier runs that occur• Establish a central oversight for all couriers • Create standard protocol for adding stops due to system
growth
Before
After
Ralph, Sr. Courier Referral LabRebecca, CourierFrank, Dir., SCS MgmtEddie (William), Sr. Materials HandlerIra, Dist. Mgr, SCS MgmtLarry, Security Officer, Eagle SecurityShannon, MIRS, Main File RoomTommy, Sr. Mailroom Tech.Peter, Assoc. Dir., Radiology
• From the end of the unit to the supply room was greater than 550 feet round trip .
• 8 trips = 2.5 miles per shift; 654 miles per year . • The staff of 3 works 12 hour shifts • Searching for supplies took too long • Staff frustrated
Goals:� Reduce walking � Reduce searching � Increase morale
Embedded Coach:Scott , Nursing Manager
Progressive Care Unit (Waste Walk)What We DidCase for Action
• Created two rooms for supplies centrally located to the staff who used them on the unit; applied 5S
• Walking reduced by 1.5 miles per shift; 476 miles per year
• Time searching reduced by 57 minutes per shift; 114 minutes per day
Expectations/Results Team
• Waste walk in the area before the unit opened to look for issues
• Used spaghetti diagrams to show nurse walking to get supplies
• Identify alternate supply space to use• Evaluated and define new PAR levels• Clear labeling of what goes where
Next Steps:• Work with Supply chain to develop robust kanban to
prevent stock outs
Progressive Care Nursing Unit & Scott
dozens
• Need to improve transition of care for patient safety & satisfaction
• Need to decrease re-hospitalizations����Medicare will no longer pay for Re-Admits
w/in 30 days
Goals:• Reduce readmissions in all DRGs w/in 30 days by 20%• Reduce Fm1 to OBS by 50%• Reduce ED visits w/in 30 days after discharge by 20%• Improved patient satisfaction (Press-Ganey questions
related to patient discharge)
• Break HUC and Case Manager/Discharge Planner bottlenecks-NVA Analysis, work level loading
• FM1 team reviewing potential discharges at 8am• Developing dedicated number to call for patients after
discharge• Develop standard work for reviewing Rx with patients prior
to discharge
Next Steps: Implement Just Do-It’sReview NVA Analysis on Case Mgr. and HUC roles,
eliminate/reduce NVA and level load NVA-required items
Hospital to Home (VSM)What We Did
Team
Case for Action
Expectations/ResultsWill, Embedded coachSondra, 6N NurseMyra , 6N HUC
Terri, Case MgmtTod, I.T. AnalystNorma , Resident
John , Resident Dir.Beth , RNSean, Home CareJoy, PharmD‘PaulaBryan , Process OwnerTiffany , MD, Process Owner
• Reduce Re-Adm in all DRGs w/in 30 days by 20%• Reduce Fm1 to OBS by 50%• Reduce ED visits w/in 30 days after D/C by 20%• Improve Pt Sat (P-G Pt D/C) by mean score of 50%• Schedule all appts .and tests prior to D/C• Decrease no-show rate on D/C follow-ups
Alma, MDJulianne, QualityAllan , MDD. Scott , MDKristyCraig, Embedded CoachBrooke, Embedded Coach
Re-casts
Are There Any
Benefits of Being
a System ?
S37
“Spread” is Step 3
1. Standardize
2. Sustain
3. Spread
38
Levels of Spread
1. Educate:• Individual: classroom, exercises, test (Lean Thinking)• Top Exec’s, Leaders, front line Supervisors – to the “tipping point”• Develop a critical mass; common language; desire/pull
2. Educate by doing: see one, do one, teach one (JIT Ed)3. Apply knowledge in one’s own area
• Individual/Small Group: Waste walks, 5S, kaizens, A3’s4. Spread to local area: pilots, PDCA’s: standard work5. Spread to “System” (multi-sites, acquired, new
construction):• System Administrator Meeting: Highlight 2 Lean projects/week• Other sites try to incorporate new Standards• New Standards stimulate System changes; other sites “one-up”
6. Spread back: Improve original Standards
B39
Hansei (Reflection)
• What We Learned (Do, Don’t):
40
Crafting a System -wide Lean Effort: What Does
Work; What Does Not
Robert W. Pryor , 254-724-5359
with Steve Hoeft , 734-395-3687
41