1. 1

2. American Society for Quality
2

3. Your Speaker
 Brian W. Hudson
 Lean Six Sigma Coordinator-FSEH
 BSIT 1990 and MSIT 1995 from Purdue University
 brian.hudson@franciscanalliance.org
 765-502-4371
 16 Years industrial experience as a Manufacturing Engineer
 15 years experience with Lean Production and Six Sigma
Associations:
 United Way LCR 2012
 ASQ Section Program Chair and Secretary
 Wabash Valley Lean Network Steering Committee
 American Heart Association Heart Walk Chair 3

4. Today’s Objectives
 Learn ways to help our organizations be more effective
 Challenge existing attitudes and processes
 Identify improvement opportunities
 Learn by doing
 Have fun
4

5. Ice Breaker
What parts of your organization do
you wish would be more efficient?
What gets in the way?
5

6. Exercise #1
6

7. Indiana General Hospital
 The Story – Lean improvement in a non-
profit environment – the Emergency room
7

8. Showing improved effectiveness in outcomes
The application process and showing outcomes for your work
8

9. The feedback from you-
The situation you are faced with:
 Greater need for our services
 Many cutbacks and things are getting tighter
 The needs of our customers continue to
increase
 Expectation of showing outcomes
 Doing more with less
9

10. Customers& Stakeholders Whatdo theyValue?
YourMission
TheVision for the Future
10

11. Your Mission
 Your mission defines your organizations reason for
existence. It embodies its philosophies, goals,
ambitions and morals.
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
11

12. The Vision for the future
 Your vision statement is your inspiration, the
framework for all your strategic planning.
 Addresses the questions
 “Where are we headed”
 “Where do we want to go”
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
12

13. Your Customers and Stakeholders
 Who are your customers?
 Who are your stakeholders?
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
13

14. Customer Value
 What do they value about your organization?
 How do you help them meet their need?
 How do you measure the value you provide?
 #/count
 Satisfaction / survey
 Outcomes
 Other
14

15. Your Core Processes or Systems
 What core processes does your organization use to
deliver the value to your customers?
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
15

16. How does it work together?
Values
Vision
Mission
Strategic plan
and
Measures
16

17. Your Resources to make it happen
 Financial
 Labor / time
 Equipment / Capital
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
17

18. The Wastes
 Identify the things that take away from the
effectiveness of your processes and systems
Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
18

19. What do Patients of Indiana General value?
 Favorable patient outcomes
 To be treated safely
 Implement new procedures & capabilities
 Slow the rising healthcare costs
19

20. 20
Example: Waking up with a crushing
headache before work
 Wake up with pain
 Call for appointment
 Go to office
 Do paperwork
 See the Doctor
 Diagnosis: migraine
 Get a prescription
 Finish paperwork
 Go to pharmacy
 Do paperwork
 Prescription filled
 Return home
 Take medicine
 Pain subsides
How long between steps?
Which steps add value?
How long is each step?
“You don't get paid for the hour. You get paid for the value you
bring to the hour.” — Jim Rohn, entrepreneur

21. 21
The aim of Lean is to meet the customer
need by understanding what they value,
then providing that value in a system
without waste

22. So then we ask-
 How do we create that value?
 What is it that gets in the way of value being “created”
 How are we addressing the things that get in the way?
The answers to these questions are the basis for
continuous improvement!
22

23. What we do well
What we struggle with
23

24. Waste
24

25. Waste
 Any activity that consumes resources but creates no
value for the customer
 Waste can be identified as anything not adding value
to the quality or delivery of the final product or
service.
 Anything our customers would not be willing to pay us
to do
25

26. Exercise #2
Please takes notes on wasteful activities you
see in your organization.
26

27. Waste in Healthcare
How much waste is present in Healthcare?
"The national numbers for waste in healthcare are
between 30% and 40%, but the reality of what we've
observed doing minute-by-minute observation over
the last three years is closer to 60%.”
 Cindy Jimmerson, medical researcher
27

28. Value-Added Activities
 Transforming materials and information into products
and services the customer wants.
Creating a
Birth
Certificate
Painting
Treating a
Patient
Receiving a
P.O.
Designing
Installing a
Phone System
28

29. Non Value-Added Activities
Operations that consumes resources (labor and
materials), but don’t add value for the customer.
Transferring
Information
Moving
Re-entering
Information
Rework
Inspection/
Testing
Waiting
29

30. Waste
 Waste is present in all work at all organizations
 The identification of waste and its elimination is the
drive for lean processes and continuous improvement.
 Recognizing waste in our organizations is the first and
most essential step in transforming waste to wisdom.
30

31. Identifying Waste
31

32. Identifying Waste
 Inventory
 Any supply in excess of customer requirements
necessary to provide service just-in-time
Organization Examples:
 Stock of forms
 Supply closets with excess supplies
 Outdated items
32

33. Identifying Waste
 Motion
 Any movement of people or machines in
excess of what is necessary to provide required services
Organization Examples:
 Traveling to get needed items or supplies
 Walking across room to answer phone
 Travelling to get the paperwork
 Hunting for coworkers
33

34. Identifying Waste
 Overproduction
 Producing more than needed or Producing faster than
needed
Organization Examples:
 Reports printed and / or mailed when not needed
 Printing extra brochures to get cheaper price
 Preparing more food “just in case”
34

35. Identifying Waste
 Over-processing
 Effort that adds no value to the product or service
Organization Examples:
 Redundant capture of information
 Ordering unnecessary workups
 Data entry into multiple systems
 Double / Triple checking
35

36. Identifying Waste
 Transportation
 Any material or information
movement in excess of what is required
Organizational Examples:
 Transporting items from location to location
 Equipment moved to patient location
 Information triplicates
36

37. Identifying Waste
 Rework / Correction
 Inspection and / or correction of information, products
or materials
Organizational Examples:
 Fixing errors made in documents
 Misfiling documents
 Dealing with complaints about service
 Mistakes caused by incorrect information
 Illegible handwriting
37

38. Identifying Waste
 Waiting
 Idle time when people wait for people, people wait for
machines, or machines wait for people
 Waiting accounts for 95% of the time that is required to
produce a product or service.
Organizational Examples:
 Patient waiting rooms
 Waiting for call backs
 Waiting for drug validation
 Waiting for equipment or supplies
38

39. We must always keep in mind that the
greatest waste is waste we do not see!
-Shigeo Shingo
39

40. Housekeeping and organization
40

41. The goal of 5S training
To introduce participants to 5S, the
benefits of workplace organization
and provide examples of successful
workplace improvements.
41

42. What is 5S?
A systemized approach to
workplace organization, to keep
rules and standards, and to
maintain the discipline needed
to do a good job.
42

43. Exercise - Handout
43

44. 10
13
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27
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62
79
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45. Importance of 5S
Quality is improved
Productivity in enhanced
Safer work environment for all
Reduced floor space
Reduced cost to operate
45

46. The 5S’s
46

47. SORTDefinition:
What is accomplished in this step:
Guidelines:
Information:
Identify and eliminate items that are not needed in
the workplace
Take old, obsolete, and unneeded items out of the
work area
For each item ask:
What is this used for?
Who uses this?
When was it last used?
When and where do we use it?
Red Tag system for unneeded items
47

48. RED TAG
 The Red Tag system is a
method used to identify
items that are found in
the work area, but their
use and need are
unknown or not needed
RED TAG
Item Description
Reason for
tagging
(circle one)
Manufacturer, part
number, serial
number
Dispositioned by
and date
Quantity and
Item value
Disposal method
(circle one)
Special
instructions
1. Item not needed
2. Excess material
3. Material outdated
4. Defective material
5. Use unknown
6. Other ____________________
1. Throw away
2. Destroy-specify date:__/__/___
3. Return to manufacturer
4. Other ____________________
Contact person for
questions

49. Additional Sort information
 Take digital pictures of current state before
starting 5S activity.
 Establish an area, cart, or table as a red tag zone.
 Place unneeded items in this area.
 Fill out red tags to determine disposition.
 When finished with elimination, take pictures of
items accumulated in the red tag area
49

50. 10
13
23
27
30
47
40
50

51. SET IN ORDERDefinition:
What is accomplished in this step:
Guidelines:
Information:
Arrange needed items so they are in good order and are
easy to find, use, and put away
Designating a location for the needed items
Store commonly used items near the point of use
Infrequently used items stored away from the area
Organize commonly used items together
Label item locations
Red Tag system for unneeded items
“A place for everything and everything in its place”
51

52. 10
13
23
27
30
47
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52

53. SHINEDefinition:
What is accomplished in this step:
Guidelines:
Information:
Clean, wipe, and sweep all of the surfaces in the
work area. Paint if necessary.
Provide a baseline for keeping the area clean and
organized in the future
Be safe!
Understand how the area became dirty and take
steps to eliminate the cause
Create an area where cleaning supplies are kept
Not just cleaning–but seeing what areas are
getting dirty 53

54. STANDARDIZEDefinition:
What is accomplished in this step:
Guidelines:
Information:
Develop a method and schedule to keep everything clean
and organized
Standardize and maintain the use of the first 3 S’s
Develop standards to organize in a consistent manner
Visually maintain conditions
Create a schedule / checklist to maintain the area
See next slide
54

55. Standardize Guidelines
 Make placement of equipment and tools
visual as follows:
 Blue tape ¼” or ½” on walls, desks, tables when marking
designated areas
 Optional in office areas
 Required in common (shared) areas
 1” or 2” Yellow tape on floor for items that move
 Required in common areas
 Storage areas marked
 Supply shelves labeled
 Digital photo posted in office area or cubicle showing
office organization
 Labels (black letters on white)
55

56. Standardize Guidelines cont’d
 Bulletin Board Information
 When submitting items for the bulletin boards, please include
the date, person responsible for information, and the date for
removal.
 Common work areas and Meeting Rooms
 Standardized Arrangement
 Standardized postings and information
 Will be framed near entrance to the room
 Documentation for training and meetings
 Standard items kept in room
 Cabinet with refill supplies to be maintained
 Specific instructions for facilitator
 Room placed in order when finished
 Lights turned out
 Items replaced as needed 56

57. Supply organization at Indiana General
Color Meaning Symbol
Red IV supplies / needles
Yellow Urinary supplies
Brown GI / Ostomy supplies
Blue Respiratory supplies
Orange ADL supplies
Green Dressing supplies
Black Miscellaneous

58. Sample meeting room layout
58

59. 10
13
23
27
30
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60. Definition:
What is accomplished in this step:
Guidelines:
Information:
Practice and repeat the procedures to have it become a
way of life
Develop a method to maintain the improvements
Audit the workplace to insure its being maintained
Review and post the audit results for all to see
This is the most critical step by maintaining the
improvements by developing discipline
“You get what you inspect – not what you expect”
SUSTAIN
60

61. 10
13
23
27
30
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61

62. 62

63. Nurses Station – Before 5S
63

64. Sort
64

65. Set in order
65

66. Shine (Clean)
66

67. Nursing Unit Example – After 5S

68. Supply Closet–Before 5S
68

69. Closet – After 5S
69

70. Sorted Items
Return to use
Trash
Donation 70

71. Other examples of 5S

72. Book Drawer Labels

73. Book Storage with Diagonal Tape

74. Cabinet Arrangement

75. Desk Drawer Arrangement

76. Desk Drawer Arrangement
What’s missing?

77. The 5S’s
77

78. 5S Benefits
 Pride in the workplace and supports team
development
 Sorting means removing unnecessary items that
congest the work area
 Clean equipment allows everyone to notice
problems
 Sorting retains only the needed items. This allows
for a smaller work area resulting in reduced effort
(walking, reaching, etc.) to do the work.
 Reduced changeover times result from being
organized and minimizing search time.
78

79.  Get everyone involved
 Integrate 5S principles into daily work
requirements
 Communicate need for 5S, roles of all participants,
how it is implemented
 Be consistent in following 5S principles in all areas
 Follow through - finish what is started - 5S takes
effort and persistence
 Link 5S activities with all other improvement
initiatives
Keys to 5S success
79

80. 80

81. Benchmarking / Best Practices
The process of comparing one’s business processes
and performance results to industry bests or best
practices from other industries.
 Collaborative benchmarking-
 Best Practices - voluntarily working with others to
develop a method that others can use
 Maybe competitors or have similar processes
Reference the “Things do well” / ”Struggles” display
81

82. 82

83. 83

84. Definition – Process Mapping
Process Mapping, often referred to as
Flowcharting, is a visual representation of the
work-flow either within a process - or an image of
the whole operation. It comprises a stream of
activities that transforms a well defined input or
set of inputs into a pre-defined set of outputs.
Source – www.isixsigma.com84

85. Processes
Series of actions that takes inputs, transforms them and
makes an output.
A process consists of repeatable tasks, carried out in a specific
order.
A set of common tasks that creates a product, service,
process, or plan that will satisfy a customer or group of
customers.
Input
Output
Activity Activity Activity Activity
Input
85

86. Inputs Process Outputs
Material
Services
Information
Documents
Scrap
By-products
Data
Reports
Material
Supplies
Energy
Information
Machines
Data
People
Methods
Services
86

87. Why is Process Mapping important?
 Help to see the bigger picture and how a process
works
 Facilitates discussion to break down ‘silo’ barriers
between functions
 Its use can reveal duplication, waste, over processing
or unnecessary steps
 It can be used to communicate the vision of where
we’re going
87

88. Symbols used in flowcharts
Start / End
Task / Step
Decision
Flow Arrow
Burst
No
Yes
88

89. #
AConnector
Document
Measurement
Delay or Wait
More symbols
89

90. Start Get bread Get JellyGet PB Apply PB&J
Open new jar
Yes
No
Assemble
sandwich
Get potato
chips
Get a drink Eat lunch End
Enough
in Jar?
A
A
Buy natural
peanut butter
Eat carrot sticks
instead of chips
Drink water
instead of soda
Flowchart Example-Making lunch
90

91. Orientation
Staff
Director
Front
Office Staff
Application ReviewApplication Review
Make sure
folder is
complete
Send folder to
faculty
committee
Send denied
letter; signed by
faculty
Share folder
with all
Review folder
materials no
yes
Send packet about
registering and
orientation
Admission
decision
Swimlane Chart
91

92. Four Techniques of Process Mapping
1. Macro (high level)
2. Micro (lists all sub-processes)
3. Current State – “as is” today
4. Future State – “could be” state
92

93. Current State vs. Future State
How the process works
today
How the process will function
after the changes
Run Cypress
reports (2X month
on 12th and 24th)
for previous month
Get reports from
Carl on 25th of
month
Linda-Develop pull
lists in Excel & notify
Michele/Cathy that it
is ready
Pull charts, put into
carts, identify, and
scan to PI
Data abstraction,
mark chart, and
update pull list
Update definitions
on worksheets &
communicate to
staff
Scan chart back to
Medical Records
File information
sheets in folders
Linda/Michele
enter information
into COP
Stop automatic print
of Cypress report on
24th (Cathy)
Have someone else
maintain pull list
from data (Linda)
Training
communication to
staff for changes
Folder with latest
worksheets
(Michele)
Cook the disk and
deliver (Due date
is1st day of 3rd month
after qtr.)
File report
COP accumulates
information and
sends CD
Copy report and
take to Committees
File report
Wait
Request for 5
charts
Send for review
after being
identified by PI
Get feedback
Is score less
than 80?
Yes
No
May appeal
End
Start
Access to QNET score - more
people with access (Linda)
Print summary
sheets of CMS
data and file
Run Cypress
report (Monthly on
12th) for previous
month
Get reports from
Carl on 25th of
month
Linda-Develop pull
lists in Excel & e-
mail staff that it is
ready
Abstract data,
mark chart, &
highlight pull list in
yellow
Update definitions on
worksheets &
communicate to staff
File information
sheets in folders
Enter information
in COP, & highlight
pull list in pink
Submit data on
website (Due date
is1st day of 3rd month
after qtr.)
COP accumulates
information and
sends CD
Copy report and
take to Committees
Wait
Request for 5
charts
Send for review
after being
identified by PI
Get feedback
Is score less
than 80?
Yes
No
May appeal
End
Start
Print summary
sheets of CMS
data and file
93

94. 1. Document the Current State map
2. Identify bursts with the current process
3. Develop the Future State map
4. Make the Action Plan to achieve the Future State
5. Work on the Action Plan
6. Go back to the beginning
How you go about it-
94

95. Looking for improvements
Ask the following questions-
 How many steps are being taken for each step?
 How many handoffs are there between staff
 Or between departments?
 How much time is taken for each step?
 What is the total time from first to last steps?
 Where do delays occur?
 What value does each step contribute?
 Where is flow stopped in this process?
95

96. Identify bursts with the current process
What quality issues exist?
Where is the process bottleneck?
Where is the process inconsistent?
96

97. Develop the Future State map
 How would the process look if we addressed all the
bursts?
97

98. A couple of additional thoughts-
 Its not rocket science-making the process map does
not have to be high-tech
 Its not about blaming or criticizing anyone or any
department
 ‘Go see’ the process
 This is only the starting point that will lead to a lot of
other improvements
 Its fun!
98

99. A
#
No
Yes
Review-
99

100. Exercise #4
 One of your processes – Using at least 4 symbols
100

101. How can you use this in your organization?
Process mapping
101

102. “Where there is no standard, there can be no kaizen.”
Taiichi Ohno
Vice-president, Toyota Motor Corporation
102

103. Exercise #5
103

104. 104
1
2 3
4
5
6
7
8
9
10
11
12
13

105. Standard Work
Defines consistent performance of a task, according to
prescribed methods, without waste, to make most
effective use of the resources
People
Materials
Methods
Equipment
Without Standard Work there can be not sustained improvement
Inconsistent
Process
Inconsistent
Results
Desired
Results
Consistent
Process
105

106. What is Standard Work?
 A simple written description of the safest, highest
quality, and most efficient way known to perform a
particular task, (i.e. a checklist to lead someone
through the task).
 The only acceptable way to do the process it describes.
 Expected to be continually improved
 Needed in most, if not, all work areas
 May be met with resistance by staff.
106

107. Standard Work
 Standard work supports the lean system of
continuously improving capacities and
efficiencies by defining 3 critical elements for
every person doing the work
1. The most efficient work routine / procedure
or steps
2. The elapsed time required to complete work
elements and move to the next step of the
process
3. Any quality checks required to minimize
defects/errors 107

108. Example of standard work (TWI)
http://www.trainingwithinindustry.net/JBS-IPOV.pdf 108

109. Standard Work information
• Includes the amount of time allotted to
hand-off the task to the next step of the
process.
• Focuses on the person, not the equipment
or materials
• Reduces variation, increases consistency
109

110. Steps for Creating Standard Work
1. Define the extent of the task for which you are
creating standard work (e.g. starts at… ends at…)
2. Determine the appropriate standard work
requirements
3. Gather best practices
4. Create the standard work document
5. Train everyone on the standard work document
6. Run the process and observe the results
7. Make adjustments and modifications to the
standard work 110

111. Tips for Creating Standard Work
DO:
 Keep standard work simple
 Make it accessible
 Include all information on one, easy-to-read document
 Create one standard work document for each part of the
process
 Always look for ways to improve the process.
111

112. Tips for Creating Standard Work
 DON’T:
• Put standard work in a desk drawer
• Change processes without changing standard
work
• Make standard work difficult to change
• Give up on standard work – it can be tough, but
it’s very important
112

113. Role of the Supervisor
The supervisor should ask the following 4 questions
for every person who will perform standard work:
1. Do you understand why it is important for you to
follow the standard work?
2. Are you willing to follow the standard work?
3. What are the consequences for choosing not to
follow standard work?
4. What is the process for changing standard work?
113

114. Exercise #6
114

115. 115

116. “To move or run smoothly with unbroken continuity, as
in the manner characteristic of a fluid.”
www.answers.com/topic/flow on 5/29/09
Customer flow – the “movement” of
customers through the process
creating value
Flow – what is it?
116

117. What does it look like?
117

118. 118

119. What is the affect of not having flow?
Not having flow creates waste-
119

120. Registration
Arrival
EKG
IR
ICU
Lab
Cath Lab
Surgery
Intake Unit
CT
X-Ray
PAT
ED
Inpatient
Rehab
Inpatient
Units
MRI
PT
Discharge
RT
120

121. And waste consumes resources
121

122. What can impede flow
and keeps us from having it?
You have to understand why flow is
not present
122

123. A. Focus on the constraint or bottleneck of the process
B. Identify how the process is inadequate–
methods, equipment, etc.
C. Changeovers take too long
D. The area is not organized and ready for work
E. Quality or scrap issues exist that consume time and
resources
Strategies for improving flow
123

124. A. Constraints and process
bottlenecks
 Every process has a constraint that limits its
throughput (capacity)
124

125. Five focusing steps
1. Identify the system’s constraint
2. Exploit the system constraint
3. Subordinate everything else to the constraint
4. Elevate the system’s constraint
5. Go back to step 1
The Goal – Eli Goldratt
125

126. vs.
Flow and Pull
126

127. 127

128. Facility layout
Making best use of
land, facilities, equipment, furnishings to deliver
value
 Facilities are expensive to obtain and maintain
 Layout can often dictate how the processes is done
in an organization
128

129. Facility Layout factors to consider
 Arrangement according to how often its used (ABC)
 Flow and steps in common processes (__ times/day)
 Specialized areas vs. flexibility in layout
 Consider other facilities at your disposal
 Have arrangement be consistent between locations
 Minimize storage and handling
129

130. 130

131. 1. Identify and define the problem
2. Organize the team
3. Describe the problem
4. Contain the problem
5. Find the root cause
6. Generate, select, & verify the corrective action
7. Implement the permanent corrective action
8. Prevent reoccurrence
9. Communicate and congratulate the team
The problem solving process
131

132. 3. Describe the problem
What do we know about the situation?
 Is this common cause or special cause?
 Collect the relevant data
 Create a process flowchart
Process step Process step DecisionBegin End
Yes
No
Process step Process step
Process step
132

133. 5. Identify the Root Cause
 Tools to analyze-
 5-why
 Brainstorming
 Pareto diagram / histogram
 Failure Mode and Effects Analysis
 Cause and Effect (Fishbone diagram)
133

134. 5 Why example –“I was late for work”
 Why were you late for work?
 Because I had to park far away
 Why did you have to park far away?
 Because the close spots were full
 Why were the close spots full?
 Because I arrived later than other people
 Why did you arrive late?
 Because I left the house late
 Why did you leave the house late?
 Because I forgot to set the alarm
 Solution - Buy an alarm you only set once and it goes off the same time every
weekday. Make sure it has battery backup in case of power failure.
134

135. Take Action
 Examine the prioritized ideas
 Develop specific action items that will address root
causes and reduce risk
 Important to assign a person responsible for each
action item, and a due date for completion
 Need to follow up on assigned actions
135

136. Hierarchy for improvement actions
 Weaker actions– Vigilance and hard work
 New memorandum, policy, or procedure
 Training and personal reminders
 Double checks
 Intermediate actions– Address Human Factors
 Redundancy, checklists, reminders
 Software modifications
 Stronger actions– Sophisticated behavioral changes
 Architectural / physical changes
 Control or interlock (force function)
 Removing unnecessary steps or ability to do task
136

137. 8. Prevent reoccurrence
Prevent it from happening again by asking the
questions:
 Where else-
 Who else-
 How else-
Revise the system as needed-
 Procedures
 Training
 Consider all current and future staff
could this exist?
could this potential problem exist?
has the same system?
has the same process?
would this be done?
137

138. Bringing it all together
138

139. Indiana General Emergency Room
 Goal Statement:
1. Improve the ‘Door to Doctor’ time for ER patients to
achieve goal of 30 minutes
2. Roll out improvements to other hospitals
 Project Scope:
Start: Patient arrival at the ER door
Stop: Time when the Patient is seen by the Physician
Includes: All ER patients entering through door
Excludes: Those arriving by ambulance
139

140. Baseline information –
Average Door to Doc- just over 45 minutes
Average Length Of Stay – About 3 hrs. 15 min.
Home Hospital LWBS
January 2006-December 2007
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
Jan-06
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Date
%RateofLWBS
Rate
Average of 1.66%
Indiana General.
140

141. Patient travel with current layout
TRIAGE
REGISTRATION
ED
WAITING
ROOM
Patient travel with the existing
layout
141

142. How the team went about it
A two-day event focusing on:
 Change management
 Process mapping
 7 kinds of waste
 Constraint management
142

143. Swim-lane chart of the process
Earlier in process on
top-later below
Several places where
waiting occurs
Kaizen bursts
Red circles indicate
the critical path
Registration ED Staff-
Bedside Nurse
Home Hospital Patient Triage and Registration Flowchart
ED TriagePatient
Pt arrives & goes to
Triage window
Take chart form & go to
Central Registration
Pt identified- Medical chart
& complaint
W AIT
Full Reg- Scan, consent,
co-pay ID, Paperwork,
insurance
Go to Triage window with
papers
Triage pt- Medical hist.,
allergies, stickers,
med rec, etc.
Patient goes to assigned
bed
Patient changes into
gown and gets situated
Patient seen by Doctor
Discharge and exit
interview
W AIT
W AIT
W AIT
W AIT
Register in Affinity
Scan, consent,
co-pay ID, insurance
Assemble paperwork and
send patient to Triage
window
Upgrade patient
Update information not
obtained at Registration
Assign pt to bed, give
report, put pt on board
Report from Triage nurse
Discharge and exit interview
Dr.’s orders
S.O. IV’s, ekg, x-ray,
blood draw
Primary assessment
c/o, hx of c/o
Clean bed, pt off tracking
board, chart to basket
W AIT
W AIT
W AIT
Triage pt- Medical hist.,
allergies, stickers,
med rec, etc.
Complaint and time of
arrival documented-send
pt to Reg
Pt arrives & goes to
Triage window
W AIT
Registration ED Staff-
Bedside Nurse
Home Hospital Patient Triage and Registration Flowchart
ED TriagePatient
Pt arrives & goes to
Triage window
Take chart form & go to
Central Registration
Pt identified- Medical chart
& complaint
W AIT
Full Reg- Scan, consent,
co-pay ID, Paperwork,
insurance
Go to Triage window with
papers
Triage pt- Medical hist.,
allergies, stickers,
med rec, etc.
Patient goes to assigned
bed
Patient changes into
gown and gets situated
Patient seen by Doctor
Discharge and exit
interview
W AIT
W AIT
W AIT
W AIT
Register in Affinity
Scan, consent,
co-pay ID, insurance
Assemble paperwork and
send patient to Triage
window
Upgrade patient
Update information not
obtained at Registration
Assign pt to bed, give
report, put pt on board
Report from Triage nurse
Discharge and exit interview
Dr.’s orders
S.O. IV’s, ekg, x-ray,
blood draw
Primary assessment
c/o, hx of c/o
Clean bed, pt off tracking
board, chart to basket
W AIT
W AIT
W AIT
Triage pt- Medical hist.,
allergies, stickers,
med rec, etc.
Complaint and time of
arrival documented-send
pt to Reg
Pt arrives & goes to
Triage window
W AIT
15 Pieces of paper
for Registration
Finding nurse to
give report
M ore in-depth
assessm ent
Searching for
patient
One person in
Triage
Adjusting tim e in
system for when
pt arrives
Pt. goes to Triage,
Registration, back
to Triage
No privacy for patient
Key
Critical Path
Im provem ent Burst 143
Indiana General

144. Inventory
 Chairs in the triage area
 Use of counter space
Motion
 Patient - 6 points before getting to a bed
 ER going to get patient – bed, nurses station
and entering into tracking board
 Going to waiting areas to find the patient
 Finding wheelchairs
 Getting gown & blanket in the room for patient
 Triage nurse leaving the triage area
 Registration walking between printers
 Sorting the paperwork – stickers
 Moving L&D patients upstairs
Overproduction
 Unneeded tests or specimens used
 Getting extra information from patient
 Only 3 face sheets needed instead of 4
Overprocessing
 Duplicate documentation like nurses
notes
Transportation
 Movement of patient
triage  registration  triage  bed
 Taking patient for Radiology or lab tests
Rework / correction
 Incorrect information for the patient
 Several calls to register one patient
 Medicaid printout / scanning - on-line
insurance eligibility
 Timely ER tracking board information
Waiting
 Waiting to register / triage
 Waiting for a bed – clean or occupied
 Results from Lab or Radiology
 Physician
 change of shifts
 seeing other patients
 waiting for a patient to get through
the process
 Clinical processing of patient
7 Kinds of Waste
144

145. The approach
 Looked at the current floor plan to see how they
could improve flow with minimal changes
 Analysis of staffing patterns – when do patients
arrive and how many staff to have
 Roles and responsibilities of the staff analyzed–
who needs to be doing what?
145

146. Improvements implemented
Changed location of the check-in desk
and made use of rarely used area
Revised the physical layout of the area
Added one additional Registration
person
Implemented the bedside and ‘Quick
registration’ process
146

147. Patient travel with the new layout
TRIAGE
REGISTRATION
ED
WAITING
ROOM
147

148. Project Results
 Reduced average LOS by 29 minutes
 Reduced ‘Door to Doc’ time by 16 mins.
 Reduced ‘Door to bed’ time by 7 minutes
 Improved patient satisfaction by 7 points
148

149.  Cross-functional team involvement
 Keep it simple when making changes
 We’re not waiting for it to be perfect
 Implementation plan
 Small scale start
 Daily debriefing to identify opportunities and
changes to be made
 Don’t sweat the big stuff
Lessons Learned
149

150. 150

151. 151

152. 152

153. 153

154. 154

155. Putting it all together
 Culture change
 Empowerment
 Vision & alignment (rowing the boat / true north)
 Sense of urgency (addressing waste, speed)
 Improvement teams, projects, resources,
 Designing new processes (cardboard mock-up),
 Overcoming resistance-facilitate / coach vs. author
155

156. Values
Vision
Mission
Strategic plan
and
Measures
156

157. Customers & Stakeholders What do they Value?
Your Mission
The Vision for the Future
157

158. Lean challenges you will face
 This is not industry, we’re not Toyota, and
we’re not making cars
 We’ve always done it this way
 We’re too busy taking care of clients
 Nonprofit world is very much siloed
158

159. What is a Lean Hospital?
It all works together without waste
Physicians
Cath Lab
Surgery
Housekeeping
ED
Radiology
Lab
HIM
Staff
L&D
PharmacyMaterials Management
Food Service
Nursing Units
159

160. Review of objectives
 Learn ways to help our organizations be more effective
 Challenge existing attitudes and processes
 Identify improvement opportunities
 Learn by doing
 Have fun
160

161. Lean organizations
Working to eliminate waste through:
 Goals and measures leading to accountability and driving
improvement
 Areas organized and arranged
 Trained and empowered staff
 Smooth and consistent processes working in unison
 Problem solving and proactive failure mode analysis
 Working to promote the value stream (service line) instead
of silos
 Getting everyone involved
161

162. Our Offer to Your Organization
 What we are offering - Partnering with our
membership on using information on improvement
projects
162

163. Reflection and sharing
 What are you going to do when you return
163

164. Additional Resources
 Local ASQ section 0917
 Brian Hudson & Sarah-Louise Kerney
 Wabash Valley Lean Network - www.WVLN.org
 www.lean.org
Recommended Readings
 Lean Thinking by Jim Womack
 Becoming Lean by Jeffrey Liker
 The Machine That Changed the World by Jim Womack and
Daniel T. Jones
 The Goal by Eli Goldratt
 Lean Production Simplified by Pascal Dennis 164

165. Additional Resources
 Gupta, Praveen. Six Sigma Business Scorecard. New York:
McGraw Hill, 2004. Print.
 Hammer, Michael and Lisa Hershman. Faster Cheaper
Better. New York: Random House Inc, 2010. Print.
 Jackson, Thomas. Hoshin Kanri for the Lean Enterprise.
New York: Productivity Press, 2006. Print
 Tague, Nancy. The Quality Toolbox. 2nd ed. Milwaukee:
ASQ Press, 2005. Print.
165

166. 166