lean doctor asq
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Lean Doctors
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Also available from ASQ Quality Press:
Quality Function Deployment and Lean Six Sigma Applications in Public Health
Grace L. Duffy, John W. Moran, and William Riley
The Public Health Quality Improvement HandbookRon Bialek, John W. Moran, and Grace L. Duffy
Root Cause Analysis and Improvement in the Healthcare Sector:A Step-by-Step GuideBjørn Andersen, Tom Fagerhaug, and Marti Beltz
Solutions to the Healthcare Quality Crisis: Cases and Examples of Lean Six Sigma in HealthcareSoren Bisgaard, editor
On Becoming Exceptional: SSM Health Care’s Journey to Baldrige and BeyondSister Mary Jean Ryan, FSM
Journey to Excellence: Baldrige Health Care Leaders Speak Out
Kathleen Goonan, editor
A Lean Guide to Transforming Healthcare: How to Implement Lean Principlesin Hospitals, Medical Ofces, Clinics, and Other Healthcare OrganizationsThomas G. Zidel
Benchmarking for Hospitals: Achieving Best-in-Class Performance withoutHaving to Reinvent the WheelVictor Sower, Jo Ann Duffy, and Gerald Kohers
Lean-Six Sigma for Healthcare, Second Edition: A Senior Leader Guide toImproving Cost and ThroughputGreg Butler, Chip Caldwell, and Nancy Poston
Lean Six Sigma for the Healthcare Practice: A Pocket GuideRoderick A. Munro
Lean for Service Organizations and Ofces: A Holistic Approach forAchieving Operational Excellence and ImprovementsDebashis Sarkar
To request a complimentary catalog of ASQ Quality Press publications, call800-248-1946, or visit our Web site at http://www.asq.org/quality-press.
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Lean Doctors
A Bold and Practical Guideto Using Lean Principles to
Transform Healthcare Systems,One Doctor at a Time
Aneesh Suneja with Carolyn Suneja
ASQ Quality PressMilwaukee, Wisconsin
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American Society for Quality, Quality Press, Milwaukee, WI 53203© 2010 by ASQAll rights reserved. Published 2010.Printed in the United States of America.
16 15 14 13 12 11 10 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Suneja, Aneesh, 1968-Lean doctors: a bold and practical guide to using lean principles to transformhealthcare systems, one doctor at a time/Aneesh Suneja with Carolyn Suneja.
p.; cm.Includes bibliographical references and index.ISBN 978-0-87389-785-3 (alk. paper)1. Medical ofces – Planning. 2. Lean manufacturing. I. Suneja, Carolyn, 1968-II. American Society for Quality. III. Title.[DNLM: 1. Professional Practice – organization & administration. 2. Delivery of Health Care – organization & administration. 3. Efciency, Organizational.4. Physician-Patient Relations. W 87 S958L 2010]R728.S93 2010610.68–dc22
2010002393
No part of this book may be reproduced in any form or by any means, electronic,mechanical, photocopying, recording, or otherwise, without the prior writtenpermission of the publisher.
Publisher: William A. TonyAcquisitions Editor: Matt T. MeinholzProject Editor: Paul O’MaraProduction Administrator: Randall Benson
ASQ Mission: The American Society for Quality advances individual,organizational, and community excellence worldwide through learning, qualityimprovement, and knowledge exchange.
Attention Bookstores, Wholesalers, Schools, and Corporations: ASQ Quality
Press books, video, audio, and software are available at quantity discounts with bulk purchases for business, educational, or instructional use. For information,please contact ASQ Quality Press at 800-248-1946, or write to ASQ Quality Press,P.O. Box 3005, Milwaukee, WI 53201-3005.
To place orders or to request ASQ membership information, call 800-248-1946.Visit our Web site at www.asq.org/quality-press.
Printed on acid-free paper
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Dedication
This book is dedicated with gratitude to
Ms. Terry Schwartz, Orthopedic Program Administrator
for Children’s Hospital of Wisconsin.
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vii
List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Introduction. 1
What Inefciency in Healthcare Settings Means for Patients . . . 2
Why Apply Lean to Healthcare Settings? . . . . . . . . . . . . . . . . . . . 3Strategic Decisions That Made Our Lean
Transformation Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6The Importance of Taking a Value Stream Approach . . . . . . . . . 8
SECTION.ONE:.Two.Strategic.Decisions . 13
Chapter.1. Begin.One.Doctor.at.a.Time . 15
Venturing into the Deep Water (One Doctor at a Time) . . . . . . . 16Lean Works Alongside other Quality Improvement Tools . . . . . 18Overcoming the ‘Flavor of the Month’ Syndrome . . . . . . . . . . . . 20Making the Critical Decisions That Will Dene Your Success . . 21Some Background: Why Pick a Starting Point, or
Model Line? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Moving on, Slowly and Deliberately, as Success Builds . . . . . . . 26Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter.2. Focus.on.Patient.Wait.Times. 29
Why Patients Care About Wait Times…and WhyThey Don’t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Wait Times Are the Starting Point, but How Do You Begin? . . . 34
Contents
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viii Contents
Collect Data About One Physician Practice . . . . . . . . . . . . . . . . . 34Value Stream Mapping Provides the Overview . . . . . . . . . . . . . . 38Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
SECTION.TWO:.The.Six.Success.Steps. 43
Chapter.3. Step.1.–.Create.Physician.Flow. 45
Analyze How the Physician Works as Part of Larger Process . . 47Creating Flow for the Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Shared Resources (How the Physician’s Time is Scheduled) . . . 50Changeover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Lean Process Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Chapter.4. Step.2.–.Support.Physician.Value-added.Time. 57
The Team Leader is Pivotal to a Lean Transformation . . . . . . . . 59How the Team Leader ‘Drives the Bus’ . . . . . . . . . . . . . . . . . . . . . 62How to Choose and Develop Effective Lean Team Leaders . . . . 66Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chapter.5. Step.3.–.Visually.Communicate.Patient.Status. . 69
Visual Communication in Healthcare: The ClinicStatus Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Why Does Visual Communication Work so Effectively? . . . . . . 74The Patient Status Board in Action . . . . . . . . . . . . . . . . . . . . . . . . . 74If Visual Communication Works so Well, Why
Not Start There? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter.6. Step.4.–.Standardize.Everyone’s.Work. . 81
Why Standard Work in Healthcare?. . . . . . . . . . . . . . . . . . . . . . . . 82The Benets of Creating Standard Work . . . . . . . . . . . . . . . . . . . . 83Process for Creating Standard Work . . . . . . . . . . . . . . . . . . . . . . . 86What Tasks Require Standard Work? . . . . . . . . . . . . . . . . . . . . . . . 89Standard Work in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
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Contents ix
Chapter.7. Step.5.–.Lay.Out.the.Clinic.for.Minimal.Motion . 93
Denition of 5S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Spaghetti Diagrams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96Why 5S is Important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Pull Systems and Supermarkets for Supplies
Replenishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Layout Considerations for the Entire Practice . . . . . . . . . . . . . . . 101Preconstruction Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 102What to Do When You Cannot Build New Walls . . . . . . . . . . . . . 105Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Chapter.8. Step.6.–.Change.the.Care.Delivery.Model. 109Old Systems, New Systems, Borrowed Systems . . . . . . . . . . . . . 110A Look Back at Changing the Model in Manufacturing . . . . . . . 110Cells in the Healthcare Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Next Steps in Care Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114This Step in Action at the Orthopedic Center . . . . . . . . . . . . . . . . 114Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
SECTION.THREE:.Lean.Leadership. 119Leadership Competency Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Working with the Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Developing Your Leadership Skills . . . . . . . . . . . . . . . . . . . . . . . . 129
Epilogue. Where.We.Are.Now. 133
Appendix.A. Introduction.to.Lean. 137
A Brief and Simple History of Lean . . . . . . . . . . . . . . . . . . . . . . . . 137Departments or Cells? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Lean Outside of the Manufacturing World . . . . . . . . . . . . . . . . . . 139
Appendix.B. Glossary.and.Explanations.of..
Lean.Principles.and.Terms. 141
Flow, Value, and Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Value-Added Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Glossary of Lean Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
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Appendix.C. .Other.Resources . 149
Appendix.D. My.Lean.Background. . 151
Appendix.E. A3.Problem.Solving.Form. . 155
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
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xi
Table I.1 Dr. Tassone Fractures Clinic results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Table 2.1 Sample waste walk form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Figure 2.1 Value stream map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Figure 3.1 FIFO lane illustration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Figure 3.2 Lean process mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Figure 4.1 Team leader organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Figure 4.2 Physician glass wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Figure 5.1 Status board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Figure 5.2 Status board in use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Table 6.1 Standard work form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Figure 7.1 Spaghetti diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Figure 7.2 Pull system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Figure 7.3 Two-door room layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Figure 7.4 Common work area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Figure 8.1 Traditional department layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Figure 8.2 Cell layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Figure 8.3 Radiology integrated within clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Figure III.1 Lean leader competency model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
List of Figures and Tables
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xiii
Irst met Aneesh Suneja about four years ago when he was broughtto Children’s Hospital of Wisconsin to nd ways we might be able toput Lean manufacturing principles to work here. He began sharing
excellent thoughts about using Lean to eliminate waste and improveour processes. I immediately realized these ideas held great promise.Although I was not exactly sure how we’d be able to apply manufacturingprinciples to healthcare, I was curious and soon, I was impressed.
Aneesh is someone who is able to give very clear explanations of rather complicated principles. His methodology is based upon soundprinciples and data—data that physicians are drawn to. He looks to under-stand why processes were put in place or why things were done a certainway and then works to support that process. He does not attempt tosimply superimpose a single solution onto all problems.
You’ll nd he takes this same approach throughout this book. Heexplains the technical principles of Lean in a very easy-to-understandand approachable way. Not only does he truly understand Lean, heunderstands healthcare. Because of this he is able to not only explainthe principles themselves, but also provide very clear, specic ways toadapt and apply these principles to hospitals, clinics, and other healthcaresettings. These principles work. We’ve seen it for ourselves at Children’sHospital of Wisconsin. And I’m condent they’ll work in your healthcaresetting as well.
I will, however, offer one word of caution: this approach is not aquick x. You will need to engage in a thoughtful and thorough process.You’ll need to be open to looking at things differently, to trying a newapproach. You shouldn’t expect instantaneous results, and you shouldn’texpect that you’ll be able to have the same success in every area whereyou implement Lean. But this is not about xing it quickly. It’s aboutxing it correctly.
Foreword
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xiv Foreword
My hope is that within healthcare we’ll be able to continue to look outside of the traditional healthcare environment for solutions—to look to manufacturing and other areas for solid, proven ideas that work.
I hope that we’ll be open-minded, and able to value and embraceprinciples like Lean in order to provide patients with the safest, highest-quality, and most efcient care. That, after all, is why we all are engagedin constantly improving.
Michael F. Gutzeit, M.D.Chief Medical Ofcer and Vice President of Quality
Children’s Hospital of Wisconsin
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xv
We would like to thank those who encouraged us to complete this book, and who offered their expertise and feedback during thewriting process: Dr. Ramesh Sachdeva, Dr. Channing Tassone,
Dr. Michael Gutzeit, Dr. Jeffrey Schwab, Dr. Kevin Walter, Dr. TomRice, Dr. Theresa Mikhailov, Mr. Larry Duncan, Ms. Lee Anne Eddy,Ms. Maryanne Kessel, Ms. Stephanie Lenzner, Ms. Allison Duey-Holtz,Ms. Sara Collins, Ms. Tracie Brasch, Ms. Lori Seubert, Ms. Beth Wahlquist,and Ms. Julie Pedretti, along with the entire staff at the Orthopedic Centerof Children’s Hospital of Wisconsin.
Many thanks to Lisa Holewa, writer, friend and cheerleader, whoseenthusiasm and journalistic instincts were indispensable in the writing of this book. And nally, thanks to our parents and our three daughters— Jaya, Mya and Emma—for their patience and support.
Acknowledgments
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1
came to healthcare after spending a decade applying Lean manu-facturingprinciplesinslightlymoretraditionalsettings,transforming theprocessesusedtomakeeverythingfromyachtsandmilitaryheli-copterstothepaintyouuseonyourlivingroomwalls.Inthisway,IcametorealizethatLean,whenapplieddeeplyandcohesively,couldtransformanyprocess.
WhenIbegantranslatingLeanto healthcare,I startedattheOrtho-pedicCenterofChildren’sHospitalofWisconsin.Theworldofpediatricmedicineissetinafragile,human,andemotionalenvironment,perhapstheplacemostunlikeanautomotiveassemblylinethatyoucouldimagine.AttheOrthopedicCenter,forexample,children’sbonesaremendedandsurgeonsworktoabatetheeffectsofscoliosisthattwistsyoungspines.Somuchdependsuponperception,intuition,andskill.
Clearly,thisisaplacewhereresultsmatter.AndsoIwillbeginbysharingthenumbers.
AsadirectresultofourLeantransformation,theOrthopedicCenterincreasedits“fracturespatientvolume”(or,moresimply,thenumberofpatientsseenwithbonefractures)by25percent,inthesameamountoftime,withthesamenumberofstaff—andusing25percentfewerexamrooms.Theimportanthealthcaremeasureof“timetonextappointment”has been reduced by more than 33 percent (from three weeks to lessthan two weeks). Weekly access for new fracture patients increased by20percent.Andtheclinichas reducedpatientwait timesbymorethan70percent.
Mostimportantly,thiswasachievedwithafocusclearlysetonqualitypatientcare.Theinteractionbetweenthedoctorandpatientintheexamroomwasleftcompletelyuntouched,withalltheotherchangesdesignedtoimprovethequalityandresultofthatinteraction.
Again, look to the numbers: the clinic has achieved instances of100 percent patient satisfaction, which is remarkable. Staff satisfactionscores have soared as well, often nearing 99 percent in internal staffsatisfactionsurveys.
Introduction
I
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2 Introduction
Asyou considerundergoinga Leantransformationprocessatyourownpracticeorclinic(orhospitalorlargerhealthcaresetting),youmightthinkthataminuteshavedoffhereandaminutesavedtheredoesnot
seemworthmuch.Changeisdifcult,time-consuming,andcumbersome.Sowhywouldyouliterallyanalyzeeverystepanursetakes?Whytakethetimetohavetechniciansornursepractitionersdescribeindetailtherealityoftheirjobs,whenyouneedthemtosimplygettheworkdone?
Why?Becauseitworks.Telladoctorthathecanseethesamenumberofpatients,offeringthesamehighqualityandpersonalcare,andhaveanextra90minutesattheendofhisclinicday—andthatmeanssomething.Tell the staff that they can look forward to actually ending on time,with satised patients, no backlog, and having focused their attention
completelyonqualitypatientcare—andtheywilllisten. Thereare, of course,manycompellingreasonsto begina Lean
transformation process, but considering the numbers is always a goodplace to begin. Imagine your clinic or practice or hospital could do25percentmorewithexactlythesameresources,simplybyrethinkingitsprocesses.That’swhatLeanisallabout.
WHAT INEFFICIENCY IN HEALTHCARE
SETTINGS MEANS FOR PATIENTSI’dliketoshiftfocusforamomentfromthedoctors,nurses,andhealth-careexecutivestothepatientstheyserve.Ratherthandiscussingdata,hereI’mgoingtoshareasimplestory.
Several years ago, my four-year-old daughter tripped in the grassand landed hard on her arm. As I watched her elbow quickly swelland change color, my heart sped with worry. Where was the nearestemergencyroom?CouldIgetherbuckledintoherboosterseatinthecar
withoutfurtherhurtingher?HowwouldIcalmher?The ensuing emergency room visit was an experience similar toonemostparentsfaceatsomepoint.Wearrived quickly andwereableto get into an exam room after a short wait in a triage area. But thenthingsslowed.Theprocessofgettingherseenbyaphysicianandintoa temporary splint took nearly three hours. Then we waited another90minutesforanorthopedicsurgeontoreturnacallaboutthediagnosis,
before the emergency room doctor simply sent us home for the night.Wewouldseethesurgeontomorrow.
Attheorthopedicclinicthenextday,Iwitnessedwhathappenswhenwell-intentionedpeopleworklikecrazyinaninefcientsystem.Certainlynoonemeanttobeinefcient.Eachindividualpersondidhisorherjobwell—fromthepleasantpersonatthefrontdesktotheempatheticcastingtechnicianwhogavemydaughterherchoiceofglittercolors.Butnoone
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Introduction 3
wasresponsibleforgettingusinandoutquicklywiththecareweneeded.Thesystemalmostseemeddesignedtomakepatientswait.Wewaitedtogetintoanexamroom.Wewaitedtogetanx-ray.Wewaitedtogeta
diagnosis.Wewaitedtogetacast.Andwewaitedtogettheeducationalmaterialsweneeded.Wetookthesewaittimesforgranted;afterall,thiswasabusyclinicandthestaffwasreallymoving—harried,even.
But,assomeonewhohadspenthiscareeranalyzinghowprocesseswork and where they break down, I knew that these wait times had
bothdeeperrootsandmoresignicancethantheobviousbusy-nessofthe clinic. For starters, the long wait times meant that there was moreopportunity for things to go wrong. On an entirely different level, thelongwaittimesmeantthattheclinicwasnotoperatingasefcientlyasit
could—that basic improvements could be made to bolster commu-nication,alignprocesses,andimpactthequalityofpatientcare.
Like any other parent, of course, I also could simply sense thatdespiteallthatactivityandhurryingaroundonthepartofthestaff,afundamental coordination was lacking. Who was driving this bus? Welefttheclinicfeelingabitunsettledanduncertain.
This story of my daughter’s broken arm and her treatment at theclinicisinnowayunique;infact,itisaprettyrun-of-themillexperience.Whatmakes the story just a bit different is, as you may have guessed,
thatIendedupinthatsameclinicafewmonthslater—thistimeasaconsultant hired to use the Lean manufacturing principles pioneered
byToyotatoeliminatewasteandimproveefciency.(Throughout this book, I’m going to assume that you have a
fundamental knowledge of Lean, and that you already know a bitabout its history, principles, and methods. This way, I can focus moredirectlyonhowtosuccessfullytranslatetheprocessestothehealthcareenvironment.Ifyou’renotcondentthatyoualreadyhaveasolidgraspon the principles, or if you’d like to learn more about the origins and
evolution of Lean, takea look at the overview inthe appendix. There,you’llalsondaglossaryoftermsandresourcesforlearningmoreaboutimplementingtheprinciples.I’malsoprovidinganoverviewofmyownexperienceandhowI’veappliedtheprinciplestoavarietyofdifferentindustries,summarizingwhatIlearnedeachstepoftheway.Beginwiththeappendixifyou’dlikeanyofthisbackground.)
Ofcourse,it’simportanttonotethatChildren’sHospitalofWisconsinalready had various quality improvement programsinplacebefore we
began our work at the Orthopedic Center. Although some healthcare
organizations have taken an “all-or-none” approach to Lean, the truthisthatitalsocanworkinconjunctionwithotherqualityprograms.I’lldiscussthatinmoredetailaswecontinue.
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4 Introduction
Clinics—fromthewalk-inclinicatthelocaldrugstorestaffedbyanursepractitionertoabustlingOrthopedicCenterinahospital
setting—provideAmericanswithamajorityoftheirhealthcare.There are more than 25,000 clinics in the United States (2002Economic Census), providing care in an estimated 500 millionvisitsperyear (Kaiser Family Foundation).
Theseclinicsrepresentahugerst-stepopportunityforimprove-mentinhealthcare.Theyareledbyaphysicianandasmallteamofproviderswhocreatetheirownprocessesandhavesomelevelofcontroloverhowthoseprocessesoperate—somethingknown
as a “healthcare microsystem.” The individual physician setsthe tone for the clinic through her scheduling preferences andmannerofseeingpatients.Assuch,thatphysicianhastheabilityto change and improve the clinic’s processes in a tangible anddirectway.
WHY APPLY LEAN TO HEALTHCARE SETTINGS?
Healthcare reform is front and center in the American political debate,anditisatopicthatdirectlyaffectsthelivesofcountlessAmericans.Itseemsnomatterwhatyouread,thesamestatisticsresurface:healthcarespendingwas$2.2trillionin2007,ormorethan16percentoftheGrossDomestic Product. Eighty-seven million people went without healthinsurance at some point during 2007 and 2008. Costs are projected toriseto25percentoftheGDPby2025.TheUnitedStatesspendsnearlytwiceasmuchonhealthcareasotherdevelopedcountries,butachievesnobetterhealthoutcomesthanmostofthosenations,leadinganalyststolabeltheU.S.systemasinefcient.
AlthoughthecomplexunderlyingcausesofinefciencyintheU.S.healthcaresystem arewidelydebated, itis muchharder tondreportsoffering solutions of any kind. So the dedicated doctors, nurses, andproviders in the trenches—like the cast tech with her red glitter for afour-year-old with a broken arm—are caught in the eye of the storm.Notsurprisingly,theyndthemselvesoverwhelmedatthemagnitudeofchangethatmustoccur,frustratedbytheirownlackofempowermenttomakeanychangehappen,andsimplytoobusyprovidingcaretostep
backandevaluatetheprocessestheyoperate.This dynamic is exactly what I found when I began working with
Children’s Hospital in 2005, starting in the Orthopedic Center and itsoperatingroom.(ImovedontoapplyLeanatChildren’sintheNeurologyclinic,theHermaHeartcenter,theEmergencyDepartment,theoperatingrooms,andtheIntensiveCareUnit,andIwilltouchuponsomewayswe
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Introduction 5
translatedtheprinciplestothoseenvironments.ButsinceourinitialworkwasinOrthopedics,wheretheentireclinichasnowundergonetheLeantransformationandwealreadyhavethedatadetailingtheimpactofour
changes,thiscasestudywillfocusonthatarea.)At the Orthopedic Center, I found talented, dedicated people who
sincerely wanted to make a meaningful difference in the lives of theiryoung patients and their families. This desire was precisely why theywentintothepediatrichealthcareeld.AndyetIfoundthattheirclinicprocesses—howtheclinicwasrun—hadmigratedawayfromtheoriginalpatient focus. Layers of handoffs and complications had been created,inlargepartbecauseofatraditionaldepartmentstructure(inwhich,forexample,“Radiology”wasaseparatedepartmentfrom“Orthopedics”).
Ialsofoundinspired leadershipready totakeon boldnew change,willing to question and challenge the “how” and “why” of their clinicprocesses.AndsomyworkwiththeOrthopedicteambeganasabitofan experiment, based on a hunch that the principles of Lean could beemployedinhealthcare far beyond the then-emerging modelofsimplyorganizingsupplycartsandusingpullsystemsfororderingforms.
As I mentioned, my experience over the previous decade imple-menting Lean in manufacturing industries had proven to me that theprinciplesofLeancouldtransformanyvaluestreamifapplieddeeplyand
asacohesivewhole.Buttheliteratureinhealthcareatthetimewaslledwithsupercialtechniquesthatcircledaround—butdidnottouch—theonecriticallynchpinintheentiresystem:thephysician.
Of course, there are a lot of reasons to leave physicians and theirworkalone.Firstandmostimportantly,physiciansarehighlyeducatedprofessionals who spend years gaining the knowledge and experienceneeded to walk into an exam room and provide an accurate diagnosisandcareplan.Rightly,fewqualityimprovementeffortswanttointrudeuponthesanctityofthephysician-patientconsultation.
Inaddition,physiciansoftenreportthroughseparatelinesofauthoritythanotherstaffattheclinic,makingitdifculttodriveimprovementsthataffecteveryone.Finally,thereissimplythefactthatthepersonbeingcalled “doctor” has a certain aura and authority that by itself createsdistancebetweenthatphysicianandtherestofthestaff.Wheretherearestrongpersonalitiesandpreferencesabouthowclinicprocessesoperate,the rest of the staff learns to work around the physician.And even inenvironmentswherethephysicianandhisstaffareonthesameteam,mosttimesthestaffwillsimplydowhattheyperceivethedoctorwants
withoutquestioningtheunderlyingprocess.Asaresult,qualityimprovementinitiativesoftenfocusontheroles
nurses,physicianassistants,clinicassistants,andothersplay—inisolationfromthephysician.Unfortunately,thisleavestheteamtomakechangesthatmaybebenecial,butarenonethelessperipheraltothe“meatandpotatoes” of the clinic’s work. No matter how efciently a patient is
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6 Introduction
checkedinorroomed,ifthephysicianisreviewingbillingdocumentsordictatingwhensheshouldbeintheexamroom,thecliniccomestoahalt.
STRATEGIC ECISIONS THAT MAEOR LEAN TRANSFORMATION WORk
At the outset, I made two strategic decisions that became formativein the creation of our Lean transformation process for healthcaresettings:rst, toworkwithonephysicianata time—withtheemphasis
both on oneand physician; and second, to focus exclusively on patientwaittimes.
Thedecisiontoworkwithonephysicianatatimemeantthatthephysicianwouldbetheoneleadingthearea’simprovementefforts.Inthis case, choosing that physician was a crucial step in beginning ourprocess. The physician had to have the potential to be a champion forLean;hehadtobeopentochangeandvaluequalityimprovement.Thephysicianandhisteamofnurses,technicians,andadministrativesupportwouldworktogethertoanalyzetheircurrentstateandparticipateinaseriesofworkshopstomakemeaningfulandlastingchange.
ThereareseveralwaysinwhichLeansolutionsarebeingusedand
testedinhealthcare.ThisincludesprovidingLeanawarenesstrainingfortheentirestaff,orcreatingvaluestreammapstoidentifyprojectsacrosstheboard.ItincludesKaizeneventsfocusedonprioritizedproblems,orimplementingoneLeantoolatatime—andvarioushybridsofalloftheseapproaches.
Inmanyimplementations,Leaneffortsbeginwithtraining—oftenalotoftrainingdeliveredbroadlyacrossthehealthcareorganization—andthenmoveontoimplementingapilotprojectortwosystem-wide.Thetrainingisdoneunderthepremisethatpeoplemustbemadeawareof
whattheLeaneffortisallaboutbeforetheycanparticipateinit.However,I have found that the traditional training-based approach is awed inseveralfundamentalways.
First,itisapushsystem.InLeanparlance,apushsystemisoneinwhichaproductismovedtothenextstepintheprocesswhetherornotthatstepisreadyforit.Whentrainingispushedontoanaudience,theinvestmentoftimeandmoneymadeinthattrainingislikelytobelostaspeoplehavenoimmediateopportunitytousewhattheyarelearning.They become frustrated or simply forget what they heard. Ideally,
improvementinitiativesandtheirassociatedtrainingshouldbe“pulled” bytheworkforcesothatthemethodologiesandthetoolscanbequicklyappliedanddonotfallondeafears.
Second, the training-then-pilot-projects approach often stays verysupercial, simply because its scope is too broad. Many healthcareorganizationsopttoconduct5Sworkshopsinmanyareas,forexample,choosing to implement one tool everywhere rather than a true Lean
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Introduction 7
systeminoneplace.OthersmightcreaterollingsupplycartseverywhereinanattempttoimplementtheLeanprincipleofminimalmotion.Othersmight implement Standard Work, Error-Proong, or Visual Controls.
It does not matter what the particular Lean tool is. In my experience,one tool applied broadly across the healthcare organization will neveryieldresultstoequalthe entire Leansystem applied thoroughlyinonephysician’sclinic.
Mynalreason for the one-doctor-at-a-timeapproachis thatbroadtraining-basedLeanimplementationstoooftengetareputationforbeingthe “avor of the month” because they lack sustainable results. It is atruthofthebusinessworld,nomattertheindustry,thatwhatgetsresultsgets paid for. Largetraining initiatives are expensive. Widespread one-
toolroll-outsareexpensive.Iftheonlyresultingmetricisthenumberofpeople trained or the number of rapid improvement workshops held,that improvement initiative will not withstand the scrutiny of cost-conscioushealthcareexecutives.Inordertolastlongenoughtohaveareal impact on the healthcare delivery system, improvement initiativesmustbemeasuredin businessmetricssuchasrevenue, cost avoidance,andoutcomes.
TheapproachItookofimplementingLeanonephysicianatatimealsohadthebenetofallowingsmallteamsofpeopletoconductquick
experimentsintheirprocessandgetimmediatefeedback.Itallowedforgreatnimblenessandfocusintheimprovementworkthatalargerrolloutwouldhaveprecludedbasedonthesheernumberofpeopleinvolved.AnditallowedtheotherphysiciansrunningclinicsinOrthopedicstoseethetargetteam’sdifferenceandwonder,forexample,whythatdoctor’steamgottogohomeontimeorwhytheirworkingenvironmentseemedlessstressful.AsthecultureoftheLeantargetclinictransformed,otherphysiciansbegantopulltheimprovementprocess,ensuringthatmoneyinvestedinLeanworkwasbeingspentwhereithadthebestchanceof
beingmetwithmotivationandenthusiasm.The one-doctor-at-a-time approach also resonated with healthcare
professionals who were used to large quality improvement initiativesimposeduponthembywhattheyperceivedtobealess-than-insightfulmanagementstructure.Focusingnotjustononeareaorspecialty,butononephysicianwithinthatarea,gavetheteamauniqueopportunitytohavetheiropinionsheardandtheirspecicissuesaddressed.EventuallytheLeantransformationreachedasmanypeopleandareaswithintheorganizationasitwouldhaveifwehadbegunwithlarge-scaletraining,
butitreachedtheminawaythatmadethemwanttorespondandengage.Thesecondstrategicdecisionwastofocusonpatientwaittimesas
themetricdrivingtheimprovementefforts.Whywaittimes?Whynoterrors, orpatientsatisfaction,or staffturnover?Whynot ascorecardofmetricsthatwouldmeasurealaundrylistofperformanceindicators?
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8 Introduction
Leanisascienceforcreatingowinasystem—whetherofaphysicalproduct or of a service. In healthcare, thiswould mean that we aim tocreatepatientow,withoutwaittimes,throughanygivenarea.Aswe
focusedonpatientwaittimesintheclinicwefoundthatnoothermetric broughtthevariedrootcausesofinefciencysoclearlyintofocus.Whenpatients were moving through the process promptly, a lot of thingsweregoingright.However,whenpatientswaitedintheexamroomsorwaitingroomsoratsupplyingprocesses,thenanyoneofagreatnumberof things could be going wrong. (If, for example, patients are waitingoutside of radiology in the Orthopedic Center, it could be because theschedulingtemplatedoesnotprovidealevelschedule,orthatradiologyisunderstaffedorequipmentisbroken,orbecausecommunicationabout
patientstatusbrokedownandnooneknowswherethosepatientsare.)Longwaittimesforpatientsalsoindicatethatresourcesintheclinic
arebeingwasted.Ifapatientisintheexamroom,waitingforservice,itmeansthatroomistiedupandnotavailableforthenextpatient.Itmeansthatstaffmembersmaymakeseveralnon-valueaddedtripsaroundtheclinic,tryingtogetthephysiciantoseethepatientortryingtoexplainthereasonsfordelaytothepatientfamily.Thequalityofcarecansufferifthephysicianismovingfromonepatienttoanotherinachaoticmanner.This experience may also turn into a patient complaint and consume
morevaluableresourcesinthehospital.I’ll use my earlier story again as an example. Despite the fact that
mydaughterandIhadascheduledappointmenttime,wewaitednearly20minutestogetintoacastroom.Didthatwaittimeindicatethatthecast technician did not know we were there? Or that the schedulingtemplatehadplacedtoomanynewpatientsinarowforthecaststaffto handle? Focusing on wait times forces the project team to uncoverthosevariedrootcausesandimplementchangestoxthemoneatatime.Further,uncovering thosecausesalso leadstodiscoveringalong chain
of inefciencies, handoffs, and errors that require the project team tocollaboratewithotherfunctionswithinthehealthcaresystem.So,askingthequestion,“Whydidtheclinicrunover45minutestonight?”canresultinimprovementsinvolvingnotonlytheclinicstaff,buttheschedulingteamandsupportfunctionsaswell.
THE IMPORTANCE OF TAkINGA VALE STREAM APPROACH
These two ideas—working with one physician at a time and focusingon patient wait times—are the key differentiators for the processdescribed in this book. In order to put these ideas into action, a clinicorpracticehastotakea“valuestreamapproach”toLeaninhealthcare.Taking a value stream approach simply means looking at the big
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Introduction 9
picture—the entire process of providing care—from the patient’sperspective. There is no room for isolated “Lean projects” in thisapproach. (Projects are often intended to implement a particular tool
ofLean,like5Sorvisualcommunication,butbecausetheyarediscon-nectedfromalargersystemperspective,theresultsthatcanbeachievedareverylimited.)
Inkeepingwiththatpatient-centeredvaluestreamapproach,we’vedeveloped six success steps to implementing Lean in any healthcareenvironment that I’d like to introduce now. These steps support theunderlying principles of making change one physician at a time andfocusing on patient wait times. Each step builds upon the previousstepintheLeantransformationprocess.Liketheunderlyingprinciples,
theywillbedescribedingreaterdetailthroughoutthisbook.Hereisaquicksummary:
1.Create physician ow: Thiscentersontheideaofthephysicianasa “shared resource”—a pacemaker in the process—who shouldneverhavedowntimeduetomissinginformationorlackofclearpriorities. Everything except the physician’s consultation withthe patient is essentially changeover and should be done asefciently as possible to set the doctor up for the best possible
patientinteraction.2.Support physician value-added time: In order for the physician to
maintainastateofowandnotexperienceunduedowntime,sheneeds a high level of coordination of clinic processes. This stepcalls for the creation of a team leader position, whose primaryresponsibilityistomakesurethedoctor’stimeisusedeffectively.Theteamleaderisusuallyanursewhohasleadershippotential;thedutiesincludetrackingthestatusofeachpatientand“drivingthebus”todirecttheclinic.
3.Visually communicate patient status:VisualcommunicationistheLeanconceptofusingvisiblemarkers,signals,andsignstocommunicatethestatusofagivenprocesssothatanyonewalkingintotheworkenvironmentcantellwhat’sinprocess,what’sworking,andwherethe problems are. With this step, I describe a seemingly simple,powerfultoolintheclinicsetting:thePatientStatusWhiteboard.
4.Standardize everyone’s work: Standard work is a tool of Lean thatprovides process stability and a mechanism for formal process
improvement. In this step the care team creates standard workfortheirprocessestondimmediateimprovementopportunities,achieve predictable outcomes, and clarify their roles in the careprocess. Creating standard work also formalizes changes madesofarandhelpstheLeansystembecomeanintegralpartofthepractice’sculture.
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10 Introduction
5.Lay out the clinic for minimal motion:Thisstepfocusesonexamininghowtochangethephysicallayoutofaclinicorotherhealthcareenvironmenttoimprovepatientowandstaffcommunication.It
usesthe tools of spaghetti mapping and 5S to look at individualworkstations, and discusses the ow of care and communicationthroughouttheclinic.SomeoftheLeanimprovementsdiscussedherearesimpleones:creatingsupplyandmaterialcarts,movingcommonly used forms and supplies inside the exam rooms,organizingpaperworkatthefrontdesk,andestablishing“pull”bycreatingakanbancardsystem.Architecturalimprovements,suchasU-shapedcelldesigns,helpdevelopanenhancedteamspacetoimprovepatientsafety,staffcommunication,andpatienthandoffs.
6.Change the care delivery model: This means rethinking the clinicprocessestofocusrelentlesslyonpatientow.TheideaoffocusingonowiscentraltoLean,becauseorganizingworkindepartmentssimply does not work. Support departments—such as radiology,casting, physical therapy, labs, echo, and pharmacy—should berethoughtandbrokenintodecentralizedmini-departments,wherefeasible. The previous steps—managing the physician’s time,visually controlling patient status, standardizing the individual
tasks in the care process—lay a stable foundation so that largerprocesschangesdonotcreatechaos.
The resultsofthisapproachareimpressive,evenmoresobecausetheyare sustainable.As I mentioned earlier, the OrthopedicCenter reducedpatient wait times by more than 70 percent, indicating that a greatmanythingsnowareindeedgoingright.Theycansee25percentmorepatientsinlessspace,andhaveachievedinstancesof100percentpatientsatisfactionscores.Staffsatisfactionscoreshaveimprovedbymorethan
25 percent, and health professionals from other areas have actuallyrequested moves into the clinics where the Lean transformation hasoccurred.(SeeTableI.1.)
It’simportanttonotethatit’snotjusttheprocessesthathavechanged.Withthecreationofteamleaders,nurseswhoaredirectlyresponsiblefortheowofpatientsthroughtheclinic,theorganizationalstructurehaschangedtosupporttheLeanvision.Further,themanagementstructurehas changed. Gone are the days of contentious relationships betweenphysicians and managers; the performance data collected by the team
andsharedwithmanagementandphysiciansallowsforbetterdecisionmaking and fundamentally changes how patient-centered issues getresolved. Physicians and managers work collaboratively because theyarealignedaroundpatientneeds,analyzethesamedata,andplayclearlydenedroles.
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Introduction 11
This book is the result of my belief in this process. These Leanprinciplesandsuccessstepswork.Theyworkinclinicsfromorthopedicstoneurologytocardiaccare—thespecialtydoesn’tmatter.Theyworkin
small practicesand largehospitalsettings.Lean methodology providesthetoolstoaddressthefrustrationspatientsanddoctorsexperienceintheclinicprocess.
TheOrthopedicCenteratChildren’sHospitalofWisconsinisnowamodelofefciencyandpatientsatisfaction,onethathospitalexecutivesand quality-minded professionals routinely tour to glimpse theseprinciples in action. Physicians have in hand all the information theyneedtoseepatientsbeforetheywalkintheroom.Theyaresupported
byateamthatunderstandswhatmusthappennextandhowtomakeit
happenefciently.Patientsspendlesstimeintheclinic,yetmoretimewith their doctor. The process moves along smoothly, the clinic dayends on time, and the staff reports less stress.Bestof all, the team hassharpeneditsfocusonthepatient,providingtopqualitycare—andstillhastimeforglitter.
A recent opinion piece in the New England Journal of Medicineurges physicians to take the lead in improving care processes:
“Healthcare microsystems are famously unreliable, variable incosts,andoftenunsafe.Physicians,throughtheirparticipationinquality-improvementinitiativesintheirpracticesandhospitals,canandshouldleadtheneededchangesinthesystemsofcarein which they work, to make them safer, more reliable, morepatient-centered,andmoreaffordable.”
Table I.1 Dr. Tassone Fractures Clinic results.
Category Before After Metric % Change
Patient Volumes Number of
(4-hour clinic)40 50
PatientsUp 25%
Space 6 4.5Number of
Down 25%Exam Rooms
Space Utilization* Number of
(PA clinic created)0 6
PatientsUp 100%
Patient Wait Times 38 11 Minutes fromDoor to Provider Down 71%
* A Physician’s Assistant clinic (during Dr. Tassone’s clinic) opened up in the
freed-up space.
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12 Introduction
Lean methodology provides the tools to address the frustrationspatientsanddoctorsalikeexperienceinthehealthcaresetting.Whatisneededisforphysicianstodrivethetransformation.
Youcanndonephysician(orbethatphysician)whocanchampiontheLeantransformationforthefrontlineinyourclinicorpractice.Takeavaluestreamperspectiveandevaluatethecurrentstatefromthepatient’spoint of view. Align the team around the patient so that the team’sinteractionsarefocusedonthatcommongoalinsteadofonpersonalitiesand turf wars. Then explore the principles and steps presented in this
book,oneatatime,andletyourLeantransformationbegin.
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15
L’s sp bak fr a mm ad mag yu’r abu ru yurrs marah. th sarg gu raks ad yu ak ff a a spr,qukly vrg h rs srh. Yu’r ahad f h pak. Yur
umbrs lk gra. Ad s yu push , full spd ahad.Bu mar hw drmd yu ar, mar hw srg, h
ruh s yu’ll s d yurslf u f brah, xhausd ad, wrs f all, whr ar h sh l. S, a mayb h w-ml mark, yudrp u. Ad yu darkly rmd yurslf: “I didn’t think I could run amarathon, anyway.”
Dsrbd hs rms, ’s lar yu s yurslf up fr falur,ha yur sragy drmd h um bfr yu k yur rssp. Y, i’d argu ha hs s xaly h apprah may halharrgazas ak wh udrakg qualy mprvm avs.Mr spally, ’s h mdl mmly advad fr La rasfr-ma prsss halhar.
th apprah gs smhg lk hs: Brg yur r halhargrup ghr fr a srs f smars ad rag ssss. th
blak h pla wh hags ha yu labl “La avs,” prhapssg up supply ars ad mvg hm lsr xama rms,r rgazg ad lag u supply rms ad srag, mayblmag a layr f paprwrk ha s dmd wasful. th rsul:ls f m ad my sp ls f ppl, wh ls f wrkrs admaagrs lf dalg wh hags hy may hav ad ad d’ruly udrsad hw susa.
My wrk mplmg La bh maufaurg ad halharsgs has vd m ha a apprah lk hs s br haakg ff fr yur rs marah a a spr, vrg sm grudqukly, bu ulmaly gg whr.
ev wrs, ’s my blf ha hs avs, hugh labld“La,” ar’ a ru rpra f h prss, whh s mr rulyhallmarkd by a bm-up (rahr ha p-dw) apprah. La s
1Begin One Doctor
at a Time
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16 Chapter One
dd by a ss f “pull” rahr ha “push”—a apprah whr hppl wh kw ad udrsad h prsss (h ppl wh auallyd h wrk) ar h s sldly bhd h hags. i rdr mak
hs happ, yu d a br pla ha vrwhlmg ppl whrag ad dag supral hags.
i’s mpra rgz ha yur gal s spr hrugh aml r w, amassg mprssv umbrs bu ulmaly falg. isad,yu shuld sar by rgzg ha a ru La rasfrma, lk amarah, rqurs srgh, sama, ad prhaps ms mpraly, affv sragy.
VENTURING INTO DEEP WATER(ONE DOCTOR AT A TIME)
i’m gg swh maphrs ad say ha a ru La rasfrmaprss s abu h rvr ha’s a ml wd ad a h dp. Aru La rasfrma gs dp h ulur f h l rpra. i’s abu blakg a rgaza wh wdsprad buulmaly shallw rag r hags. i rdr sussfully adruly mplm La h halhar sg, yu mus vur
h dp war. ths s why i ak a dffr apprah mplmgLa, bgg dr a a m.(i’s mpra hr ha larg rgazas, hs apprah
ds hav b ak qu s lrally. Wh h prpr rsurs, a b adapd, fr xampl, ma dparm a a m, r dr ah dparm a a m. Hwvr, h da s rasfrm ara bfr mvg ahr— mak ru ad dp hagsha ak hld ad h allw h hags mgra aurally as wrd f hr suss sprads.)
i my apprah, h dr ad hs am (rahr ha h rrgaza) rv h rag ad frma hy d bgmakg majr hags h prsss hy pra. thy rv jushurs bfr hy wll bg usg . thr s was h dlvry f frma.
As h physa am wrks valua s prsss ad makhags, a upl f vry pwrful hgs bg happ.
• Frs, h am s frd mprv s mmua addyams. Wh m, h vry ulur f ha am hags
lud rms suh as dug quk xprms slvprblms ral m, fusg prfrma gals rahr harprsal dramas, ad ually dsussg ways makh prss mr f ad mr ffv.
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Begin One Doctor At a Time 17
• Sd, wrd f h am’s rasfrma sprads hhalhar rgaza. i h l sg, fr xampl, hrphysas ad urss har f h mprvd prfrma ad
wrk vrm ad wa b h x La prj. As mrphysa ams ak h La wrk wh h sam apprah,h suss us buld dmad. essally h La wrk s pulld by h physas ad urss h rgaza, ad hkwldg ad xprs ar rplad.
th apprah rahs h sam umbr f ppl h rgaza asds a mr mm mass-rag apprah. Hwvr, rahs hsppl a fudamally dffr way. Rahr ha rag up fr
ad makg hags lar, ams mak sga hags fasr adga h kwldg hy d alg h way. th gagms ffrmagful, pa-rd rsuls baus hy mak magful,pa-rd hags h way h ar dlvry sysm pras.
Bfr gg mr dal abu hw mplm hs -dr-a-a-m apprah, i wa alk a b mr abu h ralsf qualy mprvm avs h halhar sg, why hsffrs f m rssa, ad hw ad why La a b dffr—ladg h way ru ad susaabl hag ha maks a ral dffr.
As w u xamg hw h orhpd cr achldr’s Hspal f Wss udrw s La rasfr-ma, allw m rdu h sm f h vsars uras sudy:
• Ramesh Sachdeva, MD, PhD, MBA, JD s h rpra vprsd ad hf qualy fr a chldr’s Hspal adHalh Sysm. H s h prs wh sparhadd h La
qualy mprvm ffrs a chldr’s, ad h xuvrspsbl fr qualy mprvm prgrams hrughuh rgaza.
• Larry Duncan s h rpra v prsd f rgalsrvs fr chldr’s Hspal ad Halh Sysms. H wash v prsd f ambulary ad dagss—vrsgorhpds, amg hr dparms, a h m w bgaur La rasfrma h orhpd cr.
• Lee Anne Eddy s h v prsd f ambulary addags srvs fr chldr’s Hspal f Wss. Shwas h drr vr svral aras, ludg orhpds,wh w bga ur wrk.
(continued)
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18 Chapter One
• J. Channing Tassone, MD s a assa prfssr f Pdar orhpds a h Mdal cllg f Wss. H
s a rhpd surg wh was ur La hamp hdparm ad hs pra s whr w bga xprmgwh La hags.
• Terry Schwartz s h prgram admsrar a horhpd cr. Sh s h admsrar i wrkd whms drly mplmg h La hags hfraurs l.
• Stephanie Lenzner, MSHA, MBA s h drr f Qualy
Daa Maagm a chldr’s Hspal ad Halh Sysm.Sh was ur las bw h Qualy Daa Maagmdparm (whh raks ums) ad h l durg urLa rasfrma h orhpd cr.
• Tracie A. Brasch, RN, BSN s a urs h orhpdcr a chldr’s Hspal f Wss. Sh bam f ur rs La am ladrs.
• Lori Seubert, RN, BSN s a urs h orhpd cr a
chldr’s Hspal f Wss. Sh als bam f urLa am ladrs.
• Allison Duey-Holtz, RN, MSN, CPNP s a urs prarfr Dr. tass. Sh was srumal sg varus Lawrkw ps ad lar ld a am f hr prs raSadard Wrk fr pa ar.
• Beth Wahlquist, RN, BSN s a urs h orhpd cra chldr’s Hspal f Wss. Sh als bam f ur al La am ladrs.
• Amy Ricely s Dr. tass’s admsrav asssa. Amghr may hr dus, sh s rspsbl fr shdulgsurgal pas.
LEAN WORKS ALONGSIDE OTHERQUALITY IMPROVEMENT TOOLS
i’s mpra ha, whl sm halhar sysms hav madwhlsal, swpg hags ad grad La arss h rrgaza, La ds hav b suh a daug all-r-prps. i hr wrds, yur gal bgg hs prss ds hav b rasfrm everything wh La. thr may b plaswh yur halhar sg ha wuld b ms frm hs La
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Begin One Doctor At a Time 19
prpls lma was ad mprv fy. Yu mgh alradyhav hr qualy mprvm prsss pla, r v a rqualy mprvm dparm. tha’s all oK. i fa, ’s ahr
ras why a -dr-a-a-m apprah wrks s wll— ffrsh xbly ad sp allw ru, dp, ad susaabl hag halhar mrsysms.
A chldr’s, i wrkd lsly wh Dr. Ramsh Sahdva, a pra-g physa ad rpra v prsd wh als has a MBA ada PhD epdmlgy. (H s ha h La ffr had h mplsuppr f chldr’s Hspal ad Halh Sysm xuv vprsd ad hf prag fr cdy chrss, addg: “if shwr mmd ha x, i d’ kw ha w uld hav b
as sussful.”)nw h hf qualy fr fr h chldr’s Halh Sysm,
Dr. Sahdva’s rsarh s fusd h ara f ums aalyss.H srvs as mdal drr f Qualy iavs fr h AmraAadmy f Pdars. H xplas ha f h sx dmss f qualy halhar s fy—ad mpraly, ha mprvgfy s’ smply abu mprvg prsss ad sdrg hrsul sla frm pa ar.
“th p s ha ’s jus h prss ha has mprvd,” h says.
“imprvg fy s h quval f mprvg qualy f ar.”Hwvr, hr ar may mhds fr mprvg fy (ad
hrfr h qualy f pa ar), ad h l shuld h prblm.“Wh a hld r pa ms s yu, yu d’ jus ra vrybdywh abs,” Dr. Sahdva s. “Yu d b abl mah hslu h sua.”
Kwg ha w wuld b sragally applyg La dra a m, ad ralzg ha h sarg p fr hs prj wuld bral s suss, h qus bam: Whr d w bg?
th chldr’s am ulmaly mad h ds bg s La jury wh h orhpd cr basd svral mpra fars,ah rlad h uqu harar f La prpls ad hfy prblms ha dd b rslvd. o majr ras frhsg orhpds was h l’s ladrshp, whh w’ll alk mrabu lar.
Ahr far, as chldr’s rpra v prsd Larry Duaxplas, s ha h l was fag ral ssus vlvg grwhad fy. orhpds was a fas-grwg dparm wh vr-
rasg umbrs f pas. i was als a “lad-lkd” dparmwhu ay spa fr physal xpas h ar fuur.
“ths was a l fag grwh whu a whl l f hr ps,”Dua xplas. “i d’ blv La s vryhg, ha ’s h rghaswr all h m. Bu ’s a l ha’s rmarkably ffv h rgh
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20 Chapter One
pla. Ad sm ways, w had a sr f ‘prf srm’ fr La orhpds.”
Smply pu: th orhpd cr had d mr, whu bg
gv mr spa. thy dd g mr u f wha hy alrady had.“W dd g h wasd m u f h sysm,” says Dua.
“ths was rally abu praal fy. if w a lma was,w a grw whu mr spa.”
i may ways, h ppl wh h l rgzd h samruh, prhaps a v dpr way. “W wr wllg gv hs a ry
baus h l was a mss,” urs tra Brash frhrghly xplas.“our vlum was gg up bu ur safg was sayg h sam. thds f h pas wr h sam, bu hr wr mr pas. S w
sad ‘F. Wha d w hav ls?’”or, as hr llagu urs Lr Subr ralls: “W wr’ akg
ar f urslvs. W wr’ gg luh. W wr’ gg u m. S w wr wllg gv smhg w a ry.”
OVERCOMING THE“FLAVOR OF THE MONTH” SYNDROME
Yu shuld rgz, f urs, ha hs “buy-” h par f hsaff was a b rlua. evry vlvd w adms havg b skpal. Ad hs s mpra rmmbr: o f yur bggsradblks wh bgg a La rasfrma s h vry fa hahr qualy mprvm avs alrady hav b rd ad fald.Wrkrs hav hard all bfr. thy’v b hr ad d ha.thy kw h mara: “Mr, br, fasr.” t may usdrs havrd bfr ll hm hw d hr jbs, may “mprvm”masurs hav m ad g.
A chldr’s, orhpd prgram admsrar trry Shwarz,wh ulmaly gudd ur ffrs hr, dsrbs as h “avr f hmh” sydrm: yu ry smhg u fr a wk r a upl mhs,lv bry, ad h mv h x gra hg.
or, h wrds f h L A eddy, h hspal v prsdvrsg h orhpd dparm (amg hr dparms): “iwas’ famlar wh La. i wrrd prhaps was jus h x gmmk.thr’s always a yl, always smhg w ry—h las bk ha’s u, h las sragy—ad smms sms w always jus d
up bak whr w sard.”Ad hs mms ar frm h ppl a h uppr rugs f maagm, h s wh hav say makg h dss. imagh rspss frm h urss, h as has, h admsravasssas—h s h fr ls, rspsbl fr aually makgh l wrk.
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Begin One Doctor At a Time 21
tra Brash, h orhpd cr urs, a ll yu abu harsps, baus sh xprd rs-had up harg ws f hLa av. As sh pus : “W’v d hs. W’v b hr. i jus
vr sks. oh my gsh, d’ ll m—hr’s ahr hg ak maway frm pa ar.”
Mr suly, frm a sr orhpd surg wh h l:“i xpd ahr xrs fuly.”
ths s why yu shuld ak La slwly. Kp h fus rmly mprvg pa ar, makg ru ad susaabl hags wh asmall, dyam, ad adapabl grup. Ad mv ly as h vdf yur suss sprads ad ppl usd f ha rs grup bmrgud. i hr wrds, prd arfully… dr a a m.
MAKING THE CRITICAL DECISIONSTHAT WILL DEFINE YOUR SUCCESS
of urs, apprahg La dr a a m mas makg svralral dss up fr. ths dss ar all abu h sargp: Whh physa wll b h bs hamp fr La? Whhmaagr a drv h La wrk frward as a hag ag? Slg
h rgh ara, alg wh h rgh hag ag ad La hamp, as yur La wrk up fr suss frm h vry bgg f h prj.L A eddy, h v prsd wh hlpd dd sar h
orhpd cr, dsrbs h prss f makg hs h basdup valuag dparm maagrs: “Wha i was lkg fr wassm wh was rsd mmdaly. W uld mak ay ladrd , bu w wad a ladr wh was larly rsd . Fr us, hawas h al hk.”
Ad s happd ha w wr xrardarly frua
bg h La rasfrma wrk wh h orhpd cr. trryShwarz, h prgram admsrar i qud arlr, ly mm-daly “rasd hr had” vlur, bu was svral hr waysh dal hag ag. Sh had a lg hsry f vlvm qualyavs ad ls, ad had b av wh h isu fr Halharimprvm (iHi) ad hr rgazas hr arr. Sh had rada amsphr h orhpd cr ha was p ryg whgs ad lkg fr ways mprv. Fr hr am b h rs hhspal mplm La smd lk a aural .
“W had rus hr,” says L A eddy, “ad sh had a rak rrd f bg a gd ladr.”i add hr xprs maagg qualy prjs, trry Shwarz
als had praal auhry h orhpd cr ad h ably mak ral dss abu prss hags. Sh udrsd hpras wll ugh hlp h am mplm hags ad rmvbsals h La wrk. Sh was wll-d h rgaza,
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22 Chapter One
ad kw ly wh vlv prblm slvg, bu hw ghs rsurs a h abl. Hr mba f qualy kw-hw,praal xprs, ad rgazaal savvy prvd b valuabl
durg h orhpd cr’s rasfrma.o w kw w wr bgg wh orhpds (basd up
bh d ad ladrshp), was m hs h physa whspra wuld b h rs udrg h La rasfrma. Ulmaly,w sld pdar rhpd surg Dr. chag tass b hLa hamp wh h orhpd cr.
Dr. tass had a muh dffr skll s. H was wll-rspd byhs am ad had fsrd a amsphr f p mmua amgh urss, urs prars, ad hr saff mmbrs wh supprd
hm. H was als p ryg w das ad larg mr abu busss ladrshp sklls ad qualy mprvm. H was a xllpubl spakr wh uld hlp sprad h mssag f La whh rgaza. Fally ad prhaps ms mpraly, h xprssd awllgss b par f h wrk—all f whh pd hm as a gdh fr a La hamp.
As h wryly xplas: “i susp i was prbably s as a wllgvm, agr ry smhg dffr.”
“Wllg vms” lk Dr. tass ar mpra. Parularly h
al sags f a La rasfrma, h -dr-a-a-m apprahwrks prsly baus h drs pull — s pushd up hm
by a qualy fu r a xuv. Ad s h physa wh bmsh La hamp mus b wllg rll up hr slvs ad dv hwrk f h am, as Dr. tass says, “agr ry smhg dffr.”th wrk a b dlgad r grd, r h rs f h pra’s saff wll ak hr u frm h dr ad prgrss wll b mad.
if yu ar sdrg a physa wh s rlua ak h ladad b h hamp, yu prbably shuld mv ad d sm
ls. D spd rgy ryg v a physa wh s uwllg.isad, d a dr wh a b husas abu h prj ad sarhr. th ds bms a ral par f yur sragy.
About the doctor as a Lean champion
S, why dr a a m? Why jus say “ maagr a a m,”r “ urs”?
W apprah La doctor a a m baus h prss f dlvrg ar, h dr s h ral lm. th dr ssallyrus a m-pra wh a hspal sg r a mdal grup. Hwha dr maags hs pra has a rmdus mpa ums,fs, pa sasfa, pa ass, ad saff mral fr hr prag grup. Whl ah physa pra s uqu (vwh h sam l r hspal vrm), La hags rarud h dr. tha dr mus b par f, ad fu wh,
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Begin One Doctor At a Time 23
whavr hags ar mad. Sh a dlga h La prj r pu f parpa.
Baus wll hag h vry vrm whh sh s
prag, ah dr mus susly dd g dw h Lapah. La a b drv p dw, r a g arud h physa fus h rs f h saff. th physa’s rl s ral, ad hmmm ad drv mus m frm h physa lvl.
Dr. tass blvs ha drs ladg h rasfrma hav b bh mmd ad adapabl.
“Flxbl—yu hav b xbl,” h lls hr drs sdrgLa. “Bu a h sam m, yu als hav b a srg ugh prs-aly say: ‘Hr ar h hgs ha d kp happg.’ Ad yu
als shuld b a prs wh’s wllg sad up ad say, ‘ths wrks.’Yu d b sm wh s wllg g u hr ad xprss hwwll wrks.”
Suh dr--dr drsm f h hags has muh mrrdbly ha sm usd h mdal ld (suh as a sula)sayg, “ths wrks.” tha, , hlps pull h av hr aras a way ha wll ras s susss. th dr s h ladr f hpra; f sh s bard ad drvg h hags, hr as sd apwrful mssag abu h mpra f h mprvm ffrs. i
s ufrualy vry asy fr rgazaal hags b grd rdsparagd, bu a rspd ladr wh prsally drvs hag amv muas.
o f h may ways Dr. tass ad trry Shwarz (h prgramadmsrar) amplshd hs was by ghr prsg prgramsabu h bs f La h hspal’s mdal ladrshp grup—hugh hy wsly rssd makg ay f hs prsas ul hyhad hard daa shar dumg h suss.
Ad wh Dr. tass alkd frmally wh fllw drs abu
h rasfrma, h says: “th bggs hg i fud myslf rpagwas: ‘Gv a ry. D’ b sard ff by h fa ha hy ar gg ask yu d hgs dffrly ha yu hav. All f us wr skpala rs.’”
SOME BACKGROUND: WHY PICK ASTARTING POINT, OR MODEL LINE?
La avs f fal h halhar sg, par du hsragy usd fr hr mplma. th favrd apprah s sar bg, hr wh brad rag whh vry s subjd rwh prjs a dz dffr aras. o h rag s mpld(ad frg) r h rgaza ralzs a maag a dzprjs, La bms jus ahr fald av ad h saff says,“I told you so.”
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24 Chapter One
our alrav apprah s vry prsly pk a sarg p, rmdl l, ad grw frm hr sm suss has b ahvd.“Mdl l” s a maufaurg rm; rfrs assmbly l
whh h La hags ar rald, s ha h am mplmg hhags a bsrv hr fay ad mpa a rlld sg.ths small hags ar wha bulds h w sysm.
As h hags ar rald ad h hr adpd r abadd h mdl l, h mdl l bgs garr h a f h rsf h rgaza baus f h mprvms ahvs. i bmsruly a mdl fr hr aras wh h rgaza, arag ral“urss” wh m s pra ad ak wha hy’v lard
bak hr aras sar hr w wrk. th prars ha mdl
l hav pprus bm spksppl fr La, dsrbghw hr prsss hav hagd ad wha h mpa f hs hagshas b.
i halhar, baus ah physa pra s uqu, hphysa’s pra bms h mdl l. Sarg wh jus physa allws h La am qukly ad asly ral small hags,prsalz hm fr h physa pra, ad buld a ffv adsussful La sysm. tha sysm s usmzd fr xaly whah physa ds ad h rumsas f ha pra, v whl
shars hararss wh La sysms gral, baus wasrad slly h x f ha pra wh h dr vlvmf h physa ad hs saff. tha kd f hag a b ahvdhrugh brad, mul-ara rllus r massv rag ffrs.
n ha h mdl l s always h ara ha ds hagh ms. th mdl l srvs svral purpss. Frs, s appruy mak sga mprvms ha aff pa
ums, pa sasfa, ad saff sasfa. Sd, sa “larg lab” whr ral La xprs a b dvlpd a small ara wh a rlld sp. Fally, ’s h s as whh vry ls lks s whhr La wll “wrk” h hspal r l. ths purpss a b ahvd f ham s uwllg, r f h physa dlgas vlvm, r f h maagr kws hg f ladg qualy prj ams—mar hw gra h ara’s d fr mprvm. Sar whryu hav ly h d, bu als a apabl maagr ad a
husas physa.
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Begin One Doctor At a Time 25
Benefts (and limitations) o the approach
Wrkg wh jus mdl l— dr—hrly lms h
sp f h La av. tha’s baus h gal s blakh rgaza wh prjs r rag, bu dlv h prvrbalml dp ara. Wh ha smallr sp, h, h La ama du quk rals f small hags ad g mmda fdbak abu hw hs hags mpa fy ad pa ar. Sussfulhags a b asly adapd by h am; usussful s hav almd mpa ad a b mmdaly abadd. th smallr spmas ha a smallr umbr f ppl wll b vlvd wh h Larasfrma. tha small am a ral hags qukly, rag h
La sysm lss m ha a av vlvg may ppl uld.i wll prvd xampls f ur sussful hags Dr. tass’sl as w xpad up h sx suss sps h x s f hs bk, bu hr wr als fald amps. Frualy, v hsability to fail hghlghs h bs hr h -dr-a-a-mapprah La. Why? Baus wh sm h am has a dar hyphss abu hw mprv fy, yu a s qukly,adapg as dd.
i as, adapa was dd baus hs parular da
fald s msrably. i w smhg lk hs: f h shdulgdfuls Dr. tass ad hs am fad was bg abl gv wpas h m hy dd durg h busy l day. i suggsdmplly sgrgag h w pas, sg asd a prd f svralhurs wh Dr. tass wuld s ly w pas.
Sadly, i dd kw ugh abu h raly f hw h lprad. i assumd ms w pas wuld brg alg x-rays adhr dags maral, bu h ruh was ha ms dd . thywuld b s ff radlgy fr x-rays, whl Dr. tass…wll, h
dd’ g a dffr xam rm s a fllw-up pa whmgh hav rqurd ly mus f hs m. n f hs paswas shduld durg hs prd! isad, h was lf sad arud,wag, ul vually w lkd a ah hr ad laughd. i qukly
bam lar ha hs shdulg mpla wuld wrk hs l,s w ddd abad h apprah.
My p? th ably qukly s a hyphss s gral Lasuss, ad h -dr-a-a-m apprah s a fudamal par f makg hs happ. i hs as, w lard a l frm ur xprm
ad ly mpad fur-hur l.Sarg wh jus dr als mas ha h hspal r la sar makg hags rgh away, whu havg rda whmay fus r ga brad apprval fr wha hs hags ar.A mvad maagr ad a mmd physa a ak sps ghr mak psv hags h ar dlvry sysm rgh w— ayar frm w afr h bard apprvs h pla.
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26 Chapter One
Rmmbr ha f h hags ur slwly, ppl hrgaza wll ls rs ad La wll bm jus ahr faldav ha “dd’ wrk arud hr.” th mmday f bg abl
s u pal hags has ahr hug b: smms hhugh f wrkg hrugh h largr rgaza g La mvg s daug v bg wrk. Sarg small maks d-abl.
MOVING ON, SLOWLY ANDDELIBERATELY, AS SUCCESS BUILDS
Apprahg La dr a a m s a dlbra, srag
ds ha wll hlp yu b sussful wh La yur halharrgaza. o warg: f h das f La ah r argaza, ad h suddly h push s ra vry, g hwrd u, ad sar ls f prjs. ths s a wll-d rsps,
bu ha rarly raslas susaabl suss.isad, w adva a muh mr masurd apprah ha sals
up vr m as suss s demonstrated , jus promised. Rmmbr:d a ara—a mdl l—ha has a ulur f qualy mprvmup whh buld, a apabl maagr vrsg pras, ad a
physa wh h lar pal b a hamp fr La. Us hs araas a larg lab du small, quk xprms wh h La lsad hqus dsrbd h rs f hs bk. th buld h Lasysm, sp a a m, wh hs hags. As h La sysm grws,d ways l yur physa hamp alk abu h hags adh susss ad pull hr physas h dsuss abu La.Us wha yu hav lard h mdl l hlp h x physarasfrm wh La.
Dr. tass dsrbs h apprah ad s mpa bs: “i k m
bg a gua pg ad my llagus sg, ‘Hy, ha wrks,” bfrvry sard sayg: ‘oK. W’ll d ha.’”nurs tra Brash agrs. “W wr h gua pg am,” sh says.
“As hgs hagd fr us, ha’s wh h hr drs k . Adhy sard rasg hr hads g vlvd.”
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ACTION STEPS
• Identifyamanagerwithinyourorganizationwhohasexperiencewithqualityimprovementeffortsandprojectteams.
• Withinthatmanager’sarea,identifyphysicianswhoarepotentialLeanchampions,whoareopentofeedbackanddirection,whohavetherespectoftheirteams,andwhoarerecognizedasleadersintheorganization.
• Workwiththeareamanagertoidentifyaphysician
withwhomtoinitiatetheLeanwork• Donotspendenergyconvincinganaysayerto
participateasthemodelline;moveontoanothercandidatetobetheLeanchampion.
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157
Aability to fail, 25action steps, 27, 41, 56, 68, 79, 92,
107, 117Anderson, Roger T.
Willing to Wait?, 31–32automobile manufacturing, 137, 149
BBalkrishnan, Rajesh
Willing to Wait?, 31–32Becher, Elise C.
Taking Healthcare Back: ThePhysician’s Role in QualityImprovement, 133–134
Becoming Lean (Liker), 149 best practices, 84BMC Health Services Research, 47
bottom-up approach to Leantransformation, 15–16, 119
Bowen, Ken“Decoding the DNA of the
Toyota Production System,” 149Brasch, Tracie A., 18
on changing mindset, 30on avor of the month
syndrome, 21
on one-doctor-at-a-timeapproach, 26on patient communication, 55on team leader role, 67, 68on trying something new, 20
on value stream mapping, 38–39on visual communication, 70on whiteboards, 71
CCamacho, Fabian T. Willing to Wait?, 31–32care delivery model (success step),
10, 109–117casting room relocation, 115cell layout
dened, 145in healthcare settings, 111–114,
112, 113in manufacturing, 138
changeover, 51–52, 78, 145Chassin, Mark R. Taking Healthcare Back: The
Physician’s Role in QualityImprovement, 133–134
Children’s Hospital and HealthSystem, 33
Children’s Hospital of Wisconsin, 4–5,33, 116
Christensen, Cindy, 19, 119clinic design, 10, 93–107clinic measurement (team leader
responsibility), 63–65, 64
clinic preparation (team leaderresponsibility), 61–62
clinic status board. See status boardclinics as healthcare microsystems, 4common work areas, 104, 104–105
Page numbers in italics refer to tablesor illustrations.
Index
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158 Index
communication, 131 barriers to, 101–102, 139with executives, 128–129
competency model, leadership,121–122, 122
core team proximity, importance of,105–107
cross training (team leaderresponsibility), 65
crystal balls, 69, 74current state maps, 39, 126
Ddata collection, 34–38, 63, 64data-driven decision making, 63data management (team leader
responsibility), 66“Decoding the DNA of the Toyota
Production System” (Spear andBowen), 149
defects (as waste), 35, 37, 143department layout vs. cell layout,
110–114, 112, 138doctors. See physiciansDuey-Holtz, Allison, 18, 91Duncan, Larry, 17
on long-term benets of Lean, 41on the value of Lean
transformation, 19–20
EE/T (elapsed time), 54Eddy, Lee Anne, 17
on nding the right physicianleader, 21
on avor of the monthsyndrome, 20
on Lean leadership, 120efciency and quality of care, 19error-proong (Lean principle), 84
executive communication (Leancompetency), 128–129, 131external changeover, 145
Ffeedback (Lean competency), 125–126FIFO (rst in, rst out) lanes, 50, 51,
74, 146Fisher, Roger
Getting to Yes, 123xed asset, physician’s time as, 32“avor of the month” syndrome, 7,
20–21ow, 49, 102–107, 141, 146. See also
wait timesfoundation steps, 109
Fractures Clinic results, 11front-line coordination, 57FTQ (rst time quality), 54Fujimoto, Takahiro
The Evolution of a ManufacturingSystem at Toyota, 149
future state achievement, 126future state maps, 39, 126
GGetting to Yes (Ury and Fisher), 123glass wall, 60, 63, 64, 66–67, 146Greenway clinics layout, 102–103, 115
HHain, Peachy B.“Improving Communication with
Bedside Video Rounding,” 66
hand-offs and transfers, 85healthcare microsystems, 4, 11healthcare statistics, 4Hospital Check-up Report: Physician
Perspectives on American Hospitals(2007), 46, 48, 127
hospital reputation, 46
Iimprovement, standard work to
capture, 84improvement initiatives, metrics for, 7“Improving Communication with
Bedside Video Rounding”(Hain), 66
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Index 159
inefciency in healthcare settings, 2–3internal changeover, 52, 146interpersonal skills (team leader
competency), 67inventory (as waste), 36, 37, 143
J Jones, Daniel, 139
Lean Thinking, 35, 149
K
kanban, 78, 99, 146Kessel, Maryanne, 134
Llead time, 39, 47leadership competency model,
121–122, 122Lean leadership, 119–129, 129–131Lean philosophy, 139Lean Thinking (Womack and Jones),
35, 149Lean transformation
and additional challenges, 134approaches to implementation, 6,
15–16, 34 business case for, 116–117critical decisions up front, 21history of, 137, 149
and other business processes, 135and other quality improvementtools, 18–20
paradox of, 119reasons for failure, 58, 81strategic decisions for, 6value of, 2
Learning to See (Rother and Shook), 39Lenzner, Stephanie, 18, 121, 124level schedules, 62, 146
Liker, JeffreyBecoming Lean, 149long-term perspective, importance of,
128, 131
M
The Machine that Changed the World (Womack and Jones), 139
management structure, 10
manufacturingdepartments and cells in, 110–111,
138front-line coordination in, 575S in, 94
metrics, performance, 7, 39, 54, 63Mikhailov, Theresa, 36, 135minimal motion (success step), 10,
93–107model line, importance of, 23–26
motion (as waste), 35, 37, 143
Nnegative perceptions, 46negotiation (leadership competency),
123–124, 129new-employee training, standard
work and, 85The New Manufacturing Challenge
(Suzaki), 149
Oone-physician-at-a-time approach, 6,
7, 15–17, 22–23, 25–26organizational support, importance
of, 126–127Orthopedic Center
background, 32and clinic status board, 76–77Lean transformation results, 1pre-Lean circumstances, 5
orthotist specialty relocation, 115over processing (as waste), 35, 37, 144overproduction (as waste), 36, 37, 142ownership, importance of, 120–121
PP/T (process time), 54paradox of Lean, 119patient advocacy (team leader
responsibility), 65
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160 Index
patient care process, 82patient-centered department
organization, 111–114
patient “families,” 112, 113patient ow. See also wait times
and clinic status board, 76as quality metric, 8
patient satisfaction, 10, 31–33, 46, 47patient wait times. See wait timesPedretti, Julie, 46
on family-centered care, 56on process improvement, 110on using Lean to provide better
care, 116–117performance metrics, 63, 64physician ow (success step), 9,
45–56, 106physician Lean process map, 53physician value-added time
(success step), 9, 57–68physician–patient interaction, 30physicians
and core team proximity, 11
as Lean champions, 5–6, 22–23, 120,126–127
personality and interpersonalstyle of, 34
and quality improvementsystems, 11
as shared resources, 50, 51unsuitability for team leader
role, 58poke-yoke (Lean principle), 84portability of services, 107problem solving form, 155problem solving (team leader
competency), 66–67process, importance of dening, 81process improvement, 83–84, 109–110process map, 147process mapping, 52–56, 53process stability, 110
product-focused cells, 138pull systems in Lean, 6–7, 16,98–101, 100, 119, 147
push systems in Lean, 6, 16, 147
QQuality Data Management (QDM)
team, 63quality improvement initiatives,
5–6, 11
Rradiology department relocation, 116recognition (Lean competency), 130resource utilization, standard work
and, 84
Results from the Heart (Kyoshi), 149Rice, Tom, 134–135Ricely, Amy, 18
on staff satisfaction, 30on standard work, 83
Robert Wood Johnson Foundation“Transforming Care at the
Bedside,” 139roles and expectations, standard
work and, 85, 89
Rother, MikeLearning to See, 39
S5S approach to Lean transformation,
6–7, 38, 94–96, 98, 145Sachdeva, Ramesh, 17, 119
on clinic status board, 74–75on management commitment, 19
scheduling templates, 25, 62Schwartz, Terry, 18
and clinic layout design, 102–103on clinic status board, 75as early volunteer, 21–22on avor of the month
syndrome, 20and Lean champion selection, 23and personal credibility, 125on team leader compensation, 61
on the value of data, 47Seubert, Lori, 18
on available time, 32on clinic status board, 76on data collection, 63, 65on team leader role, 59on trying something new, 20
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Index 161
shared resources, 9, 50, 51, 147Shook, Dan
Learning to See, 39
Six Sigma, 135spaghetti diagrams, 96–98, 97, 101, 147Spear, Steven
“Decoding the DNA of theToyota Production System,” 149
staff buy-in, 20–21staff satisfaction, 1, 10, 30standard work (success step), 9, 81–92
benets of, 83–86contents, 81–82
dened, 147document creation process, 86–87documents, 88what it’s not, 83
starting point, importance of, 23–26status board, 70–73, 72, 73
adapting to, 125resistance to, 75team leader’s responsibility for, 78as transformational tool, 74
strategic thinking (Lean competency),126, 130
success statistics, 10, 11success steps, 9–10
change of care delivery model,109–117
clinic layout for minimal motion,93–107
physician ow, 45–56physician value-added time, 57–68standardized work, 81–92visual communication, 69–79
Suneja, Aneesh, 151–153supermarkets, 98–101, 148supplies replenishment, 98–101sustain (5S element), 99sustainable results, 7, 10, 26Suzaki, Kyoshi
The New Manufacturing
Challenge, 149Results from the Heart, 149
TTaking Healthcare Back: The Physician’s
Role in Quality Improvement(Becher and Chassin), 133–134
Tassone, J. Channing, 18on casting room relocation, 115on clinic status board, 74, 78as rst Lean champion, 22Fractures Clinic results, 11on Lean leadership, 120on one-doctor-at-a-time
approach, 26
on patient attitudes toward waittimes, 31on physician’s role in Lean
transformation, 23on professional communication, 115on quality of patient care, 30on satisfaction with Lean
transformation, 133on standard work, 90, 91on waste walks, 38
team leader organization, 60team leader position
management support for, 67tactical benets of, 59transformational benets of, 59–60
team leaderscompensation for, 61competencies of, 66–67dened, 148in manufacturing, 57
physical location and creating ow,106–107
practice nurse as, 106primary clinic-based functions,
61–65responsibility for clinic status
board, 78role of, 9, 58, 60standard work for, 88
tennis ball exercise for process
development, 109–110top-down approach to Lean
transformation, 15–16Toyota Production System, 137, 139training, standard work and, 85training-based approach to Lean, 6–7
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162 Index
“Transforming Care at the Bedside”(Robert Wood JohnsonFoundation), 139
transparency, performance, 63, 64transportation (as waste), 36, 37, 144two-door room layout, 103, 103–104
Uunderstanding Lean principles (team
leader competency), 67Ury, William
Getting to Yes, 123
Vvalue-added activities, 141–142, 148value-added time, 39, 47value stream approach, 8–12value stream mapping, 38–41, 40, 148visibility (Lean competency),
124–125, 130visual communication (success step),
9, 69–79visual control, 148
WWahlquist, Beth, 18
on clinic status board, 75on standard work, 90
wait times, 29–41and clinic status board, 78as ideal quality metric, 29as indicator of inefciency, 29patient attitudes toward, 31–33root causes of, 8strategic focus on, 7–8training course simulation, 31
as waste, 35, 37, 144waste, 35, 148waste of motion, status boards and, 74waste walk, 35–38, 37wasted resources, 8, 32wastes, process or system, 142–144whiteboards. See status boardWilling to Wait? (Anderson, Camacho,
and Balkrishnan), 31–32“willing victims,” 22
Womack, James, 139Lean Thinking, 35, 149work processes and ow, 106workarounds, 58
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Established in 1946, ASQ is a global
community of quality experts in all fields
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The Society also serves as an advocate
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Belong to the Quality Community!
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Visit www.asq.org/membership for more information on ASQ membership.
*2008, The William E. Smith Institute for Association Research
ASQ MembershipResearch shows that people who join
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Have the opportunity to meet,
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Access a wide variety of professional
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Visit www.asq.org/certification to apply today!
ASQ CertificationASQ certification is formal recognition
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ASQ Training
Classroom-based TrainingASQ offers training in a traditional
classroom setting on a variety of topics.
Our instructors are quality experts
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