Leveraging Lean in the Emergency Department Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation

This book is part of a series of titles that are a spin-off of the Shingo Prize-winning book Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System. Each book in the series focuses on a specific aspect of healthcare that has demonstrated significant process and quality improvements after a Lean implementation.Emergency departments have become notorious for long wait times and questionable quality of care. By adopting Lean manufacturing concepts, hospitals can turn the emergency department into a valuable service for the hospital and the community it serves.Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation supplies a functional understanding of Lean emergency department processes and quality improvement techniques. It is ideal for healthcare executives, leaders, process improvement team members, and inquisitive frontline workers who want to implement and leverage Lean.Supplying detailed descriptions of Lean tools and methodologies, the book identifies powerful Lean solutions specific to the needs of the emergency department. The first section provides an overview of Lean concepts, tools, methodologies, and applications.The second section focuses on the application of Lean in the emergency department within the confines of the hospital or clinic. Presenting numerous examples, stories, case studies, and lessons learned, it examines the normal operation of each area in emergency departments and highlights the areas where typical problems occur.Next, the book walks readers through various Lean initiatives and demonstrates how Lean tools and concepts have been used to achieve lasting improvements to processes and quality of care. It also supplies actionable blueprints that readers can duplicate or modify for use in their own institutions. Illustrating leadership’s role in achieving departmental goals, this book will provide you with a well-rounded understanding of how Lean can be applied to achieve significant improvements throughout the entire continuum of care.

Introduction to LeanThe Need for ChangeNational and Global CompetitionChallenges for the Healthcare Worker Lean and LayoffsTraditional Healthcare ModelIntroduction – So What is Lean? Lean and Hospitals What Results can you Expect?The CEO and LeanTypical Lean Metrics and Outcomes Potential Lean Returns by Department Typical Results/Return on Investments (ROI) and Implementing LeanLean and Systems Thinking Boiled Frog Syndrome Systems Thinking Principles Viewing the Hospital with Systems ThinkingWhat is a Lean Business Delivery System? Lean Business Delivery System Vision Understanding the Value of the Lean Business Delivery System Just In Time: The First Pillar of the Toyota Production System Model An Example of One of the Rocks—Short-Staffed Jidoka—The Second Pillar of the Toyota Production System Jidoka Means: Never Pass on a Bad Part or Patient Applying Jidoka to HealthcareThe Top of the Toyota House—Respect for HumanityLean is a JourneyBatching vs. Lean Thinking and FlowBatching vs. Lean Thinking and FlowBatching vs. Flow in a Healthcare Environment Bathing Examples Process Definition Batching Systems Why People Love to Batch? One-Piece/Patient Flow One-Piece Flow ExampleGroup TechnologyProductivity - DefinitionBatching The Domino EffectPeak Demand Examples of Batching in Healthcare Chart PreparationApplication of One-Piece Flow to HealthcareFlow—One-Piece Flow or Small LotLean and Change ManagementImplementing Lean is about BalanceLean Culture Change Paradigms Change Equation C · Compelling Need to Change Why Change? V · Vision N · Next Steps Change and What’s In It For MeLean and Change ManagementLean and Organizational Change - "Right Seat on the Right Bus" Resistance to Change Changes… Highs and Lows Rule of Unintended Consequences and Bumps in the Road Change is a Funny Thing We are all Interconnected but not Typically Measured that Way Horse Analogy Comparison to Where We are Today Employee Suggestion Systems Barriers to Change Most Loved Words Does Your Organization have Sacred Cows?Leadership and Organizational ChangesCommunication, Change and Lean SummaryLean FoundationLean Foundation Baseline in the Basics ModelThink—See—Act LeanSystem Lean Implementation Approach Utilizing the Basics Model A Customer Service StoryBaseline Metrics Data, Revenue, and HospitalsThe Impact of Data on Lean – Process Focused Metrics Customer Satisfaction Voice of the Customer SurveysThe VIP Visit Easy to Do Business WithCentralized = Batching What Does All This Have to Do with Hospitals?Customer Value-Added Proposition Customer Quality IndexBaseline the Process Value Stream Map (VSM) the Process Value Stream Discussion Value Stream Mapping and Healthcare Value Streams Objectives Traditional Hospital Systems - SILOS Lean Goals Parts of a Value Stream Map Value Stream Map Icons Value Stream Map Definitions Day 1 Day 2 Day 3 Day 4Day 5 Current State Value Stream Mapping Ideal State Future State Value Stream Mapping Value Stream Map Project Lists, Prioritization Matrix, and Tracking Value Stream Layout Maps (sometimes referred to as Skitumi maps)Baselining the Process—Data Collection and Analysis—Current State Takt Time/Production Smoothing Available Time Customer Demand Peak Demand Cycle Time Cycle Time and Takt Time—What’s The Difference? Designing Cycle Time to Takt Time Length of Stay (LOS) Length of Stay (LOS) Length of Stay is Directly Correlated to Inventory Length of Stay—A Key MetricReducing Length of Stay Number of Staff Required Total Labor Time Quiz Weighted AverageFinancial Metrics Measuring Inventory and Cash Flow Work in Process Inventory Sales of Reimbursement per Employee Contribution Margin Cost Per Case Data and What People ThinkSustainability and Accountability Process Owners Do Not Always have the Skill Sets Necessary to Manage in a Lean EnvironmentNotesBasic Lean Concepts and Tools – Assessment and AnalyzeLevels of Waste Low-Hanging Fruit Five S Wastes The Seven (Eight) WastesHow do you Find Waste? 30-30-30 Exercise People Equipment Communication Visual Controls LeadershipCost of WasteBaseline Entitlement BenchmarkFive Why’s ExampleAnother Tool to Get Rid of Waste: The Five W’s and Two H’sRoot Cause Analysis—A3 StrategyFishbones and LeanProblem-Solving ModelProblem StatementsLean Tools - Analyze/Assessment BASICS—Assess the Process Step One: Understand and Assess the Overall Process Value-Added Non-Value-Added Activities/Work Non-Value-Added but Necessary Work Unnecessary Work Idle Time Warranted IDLE Time ExceptionsThe Patient Physical ExaminationStep 1: Process Flow Analysis (PFA)—Following the Product/Patient Mapping the Process—Identifying Process BoxesProduct Process Flow Analysis ToolThe Four Components Of PFA - Tips AnalysisBasic Lean Tools Understanding Types of Storage Raw Material Storage Work in Process Storage Finished Goods Storage Further Delineating Storage—Types of Work in Process Lot Delay Potential Lean Solution Example #1 Potential Lean Solution Example #2 Between Process Delay Within Process Delay Why Break Down Types of Storage? Total Throughput Time Product Process Flow Worksheet Product Flow Point-to-Point Diagrams How to Do a Point-to-Point Diagram Network of Process vs. Operations DefinedGroup Technology Matrix—Stratification Analysis Example: Group Technology Applied to a Surgical Services UnitStep II: Assess the Process—Operator Analysis or Full Work Analysis Why Make the Operator’s (Staff Person’s) Job Easier? Total Labor Time Workload Balancing How To Balance The Work Separate Worker from Machine Machine Time vs. Labor Time Diagrams: Spaghetti Diagramming—Operator Walk Patterns How to Do a Spaghetti Diagram Network of Process vs. Operations DefinedMotion Study—Just When You Thought You Were "There" Time is a Shadow of Motion 100% Efficiency with Humans Operator ResistanceStep III: Assess the Process—Changeover Analysis Internal Vs External Time Four Parts of a Setup/Changeover Process Healthcare Setup Translation Why Reduce Setups? Benefits of Smed/SMER (Single Minute Exchange of Rooms)SummaryPutting It All TogetherUnderstanding Demand and Resource NeedsAppropriate Resourcing Can Drive Metrics True Bottlenecks Cross-Training How to Construct a Cross-Training MatrixHeijunka—Sequencing Activities, Load BalancingStandard Work Story Job Breakdown/Work Flow AnalysisDeveloping Standard Work Standard Work Form Work Standards Eventually Standard Work Can Lead to Semi- or Complete Automation Leader Standard Work Capacity Analysis—Part Production Capacity SheetLayout Design Master Layouts Creativity Before Capital Lean Layout Design—Configurations—Determining the New Flow for the Area The "U-Shaped" Layout Straight Line Layouts Parallel Layouts Other Layout Considerations Guidelines to Layout Re-design—Non-Negotiable How Do We Know When the Layout is Right? Work Station Design Stand Up vs. Sit Down Stations with Chart Flow Work Station Design SummaryMaster Layouts and Lean Design Lean and Architects Do We Really Need to Add More Rooms or Space? Layouts Drive Waste in the Form of Increased Labor Costs—Consider Adjacencies Some Practical Examples of Lean Designs Nursing Floors Other Design ConsiderationsLean and Regulatory Environment Rate Companies on the Ability to Sustain Continuous Improvement Plan for Every Part—Amount of Supplies/Inventory Needed Labeling Kanban What Parts Do We Kanban? Constant Time or Constant QuantityImplementing Lean in a Healthcare EnvironmentHow to Implement Lean MethodologyThe Lean System Implementation—Are You Ready for It? What Type of Commitment is Required? What is Kaikaku? Kakushin Importance of Lean Pilots Keep the Ownership with the Line OrganizationLean Implementation Objections and Retail Sales Techniques Objections are Good! Types of Closing QuestionsGeneral Overarching Lean Implementation TipsTeam Charters Guidelines for the Supervisor Train the Staff in the New Process Types of Training Overview Training On the Job Lean Training Executive TrainingThe Lean Implementation Model Genera

W. Protzman, III, MBA, CPM is a Shingo Prize-winning author and internationally renowned Lean consultant with over 31 years’ experience in materials and operations management. He spent more than 13 years with AlliedSignal, now Honeywell, where he was an aerospace strategic operations manager and the first AlliedSignal Lean Master. He has received numerous special recognition and cost-reduction awards. Charles was an external consultant for DBED’s World Class Maryland Consortium while he was with AlliedSignal. He had input into the resulting World Class Criteria document and assisted in the first three initial DBED World Class Company Assessments. Charles has taught students in Lean principles and Total Quality from all over the world.In November of 1997, Charles Protzman formed Business Improvement Group, LLC (B.I.G.). B.I.G. is located in Baltimore, Maryland and specializes in implementing Lean Thinking. Charles has spent the last 18 years implementing successful Lean product line conversions, kaizen events, and administrative business system improvements (transactional Lean) across the globe.Charles participated in numerous benchmarking and site visits including a two-week trip to Japan in June 1996 where he worked with Hitachi in a kaizen event. He is a Master facilitator and trainer in TQM, total quality speed, facilitation, career development, change management, benchmarking, leadership, systems thinking, high performance work teams, team building, Myers Briggs Styles Indicator, Lean thinking and supply chain management. He also participated in Baldridge Examiner and Six Sigma management courses. He was an assistant program manager during Desert Storm for the Patriot missile-to-missile fuse development and production program.Joyce Kerpchar, PA is a Shingo Prize-winning author and health care expert, with over 30 years of healthcare industry experience and currently serves as a director at Florida Hospital Orlando, which is part of the Adventist Health System, an acute-care, tertiary hospital caring for more than 1.5 million patients a year. She joined Florida Hospital in 2001, and has held a variety of roles, as interim director of strategic for surgical services, director of the Institute for Surgical Advancement, a senior consultant implementing Lean across the eight campuses in a variety of clinical departments, is a Six Sigma Black Belt and is a certified MBTI instructor, product and project manager roles developing and implementing software applications.She began her career as a board certified physician’s assistant in cardiovascular and thoracic surgery and primary care medicine. Prior to joining Florida Hospital, she held a variety of administrative positions in healthcare-related industries, which included managed care operations and contracting for a PruCare/Prudential Healthcare who served 200,000 members in nine counties in Central Florida, Product Management for Avio Corporation, a provider of information technology for ambulatory healthcare organization, and was a partner in a consulting firm which specialized in business and market entry strategy for high tech start-ups.Ms. Kerpchar is passionate about leveraging Lean in healthcare processes, to eliminate waste and reduce errors, to improve the overall quality and reduce the cost of providing healthcare. Dr. George Mayzell, MD, MBA, FACP is the senior chief medical officer and chief clinical integration officer for Adventist Midwest Health. He joined the organization in January 2013 after serving as CEO of Health Choice and senior vice president of Methodist Le Bonheur Healthcare in Memphis, Tenn.Dr. Mayzell has more than 30 years of experience in medicine and is a board certified internist and geriatrician. He received his medical degree from the University of Medicine and Dentistry of New Jersey and his MBA from Jacksonville University.He previously served as senior medical director of managed care for University of Florida and Shands Hospital. He spent more than 10 years with Blue Cross Blue Shield of Florida, working as regional medical director for care and quality and corporate managing medical director for pharmacy and care. Additionally, he has more than 10 years of practice experience.Mayzell has co-authored two books, Leveraging Lean in Healthcare and Physician Alignment: Constructing Viable Roadmaps for the Future.