1. Introduction to
Lean
Leadership InstituteLeadership Institute
&&
Performance ExcellencePerformance Excellence

2. AgendaAugust 16, 2013
• Welcome, Objectives, Expectations
• Lean Background/ History
• Kaizen Overview
• Lean in Healthcare
• Dot Simulation 1 Exercise
• Value & Waste Overview
• Kaizen Process
• Lean Tools: Circle of Work / Spaghetti Charts
• Lean Tools: TAKT Time
• Lean Tools: Push vs. Pull
• Lean Tools; 5S and visual controls
• Kaizen: Observing the Current Process
• Dot Simulation 2 Exercise
• Lean Tools: Set up Reduction
• Developing the future state
• Kanban and Single Point
• Dot Simulation 3 Exercise
• Creating a new Standard Work
• Error Proofing
• Dot Simulation 4 Exercise
• Dot Exercise Debrief
• Summary and Wrap up

3. Session Objectives
• Provide an Introduction to Lean
• Identify Lean Principles
• Define Value, Non-Value Added work and
Waste
• Identify Lean applications in healthcare
• Apply the Lean tools within the Healthcare
environment
• Provide a description and understanding of
Kaizen events

4. Kaizen Definition
Thoughtful Acts of Continuous ImprovementThoughtful Acts of Continuous Improvement
To take apart and
make new
To think about so as
to help others
Eliminate WasteEliminate Waste
Solve ProblemsSolve Problems
If the first fix doesn’t work, try againIf the first fix doesn’t work, try again

5. Lean is …..
• A set of operation concepts
• A set of tools used in a variety of
industries – including service &
healthcare to improve business processes
• A philosophy that helps drive efficiency
and speed through employee
empowerment and change at the grass
root level

6. Benefits of Lean
Lean attacks waste in any process or value
stream
•Higher customer satisfaction
•Reduced cycles
•Better delivery
•More capacity
•Better quality and safety
•Improved productivity

7. History of Lean
• Lean Manufacturing began as the Toyota
Production System (TPS)
• Lean came to the US in late 1980’s
• Healthcare Providers (Early Adopters) in
the US began to embrace Lean Enterprise
concepts about a decade ago
• Insurance Companies and Insurance
Providers demanding that Healthcare
Providers embrace Lean Concepts

8. Kaizen

9. House of Kaizen

10. Kaizen Training
10
Do MORE with LESS
Waste Productivity
Staffing Productivity

11. Kaizen Training
11
Standards
Enforce
Inspect
.
Stabilize
Identify
Waste
Im
prove
Problem Solve
Standardize
• Process requires ongoing inspection and enforcement to
ensure “Standardized Work” is being followed
• Process does not improve automatically
- Following standards will only maintain, not improve, the process.
- Improvement focuses on the entire process.

12. Why does Lean apply to
healthcare?
• Tools easy to learn / teach
• Learn by doing
• Easier to apply at frontline where work is
really happening vs. other methodologies
• Improvement occurs with the first
application

13. Lean Opportunities in
Healthcare
Emergency Reducing Wait Times
Surgery OR Throughput
Radiology MRI/CT Throughput
Admission Bed Turnover

14. Understand flow of materials, information and people through the hospital,
then identify tasks or activities (operations) that improve or hinder flow
1. Understand who the customer is
2. Solve the customers problem completely
3. Understand the value you provide
4. Manage by observation facts...do not make decisions
based on reports
5. Involve people closest to the problem…team-based
environment
6. Drive to root cause
7. Try storm, take action now!!
8. Standardize – Discipline
9. Sustain through customer focused cycle time &
process metrics
Lean Principles

15. Break-out
Simulation

16. The Dot Simulation
Demonstrating Basic Lean Principles
Background Information
You are workers in the Outpatient Radiology department of a hospital.
Using colored dots on a sheet of paper, we will simulate the major
steps in processing a patient through a radiological exam.
Red Dots = Reception
Green Dots = Registration
Orange Dots = Patient Preparation
Blue Dots = Exam
Yellow Dots = Check films
We will run four round of the simulation. At each stage, you will have
opportunities to improve the process, using some of the Lean
principles we’ve studies.
As you participate in the simulation, think about other hospital
processes where these principles might help you reduce waste and
improve efficiency; admitting a patient to a nursing unit, coding,
documenting a patient’s chart, etc.

17. Intro to Overall Simulation
Care Process Templates
Dots:
Reception
Registration
Patient Prep
Exam
Check Films
Red Green Orange Blue Yellow Red Green Orange Blue
Yellow
Completed Care
Patient Care process

18. Roles and Responsibilities
Materials manager
•Record the time on the batch when the process is started. Move the batch
to Reception (Red Operator). Only send one batch at a time to the Reception
•Stock Room Management: Give out dots when the process workers come to
you. You may only give out one sheet of dots at a time and only when the
process worker has a signed requisition form from a VP.
Process Workers (1 person per color)
•Apply colored dots on the paper as indicated by the customer when a batch
is received
•Deliver it to the next station. Send only one batch at a time.
•Get additional dots from stock as needed. Only one sheet of dots per visit
to the stock room is allowed. You must obtain a signed requisition form from
a VP to get a new sheet of dots.
•Any defective batches returned to your station take first priority. They must
be fixed and sent back through the process

19. Roles and Responsibilities
Patient / Inspector
•Receives batches from Yellow Operator and inspects for
meeting quality requirements. If the batch passes, records the
time that a completed batch passed through inspection, places
them in the completed bin, and tell the patient it’s ok to leave.
(Write the completion time on the unit, fold the unit in half and
place it in a location indicating that it has been finished). If the
batch does not pass, take it back to the work station responsible
for the problem. Keep a record of batches that were sent back
to be fixed and batches that were accepted using the inspection
sheet.
Recorder
•On the flipchart, track the Inspection Sheet data and the
Process metrics for each of the rounds

20. Simulation Round 1
• Run for 5 minutes
• Colors must be applied in sequence – first Red, then Green,
Orange, Blue, and Yellow
• No process changes allowed during the round – we want to
understand and baseline the current process
• If the process workers run out of dots, they must complete a
Materials Requisition Form and get it signed by a VP before
requesting more dots from the Materials Manager
• When Reception (the Red Operator) finishes a batch, he /
she must ask the Materials Manager for a new batch
Have Fun!!

21. Report Out

22. 22
SHIFT MINDSET
CURRENT
THINKING
REQUIRED
THINKING
WASTE NOT DEFINED
REACT TO LARGE EXAMPLES
REACTIVE IMPROVEMENT
WASTE IS "TANGIBLE”
IDENTIFY MANY SMALL OPPORTUNITIES
-LEADS TO LARGE OVERALL CHANGE
CONTINUOUS IMPROVEMENT
WASTE
TYPES
OF
WASTE
Correction
Processing
Motion
Waiting
Inventory
Transportation
Over-
Production

23. Value and Waste
Value
•An activity that the customer is willing to pay for
•An activity that physically alters the existing state
•Who are your customers
•What is “Value” for YOUR customer
Waste (Muda)
•An excessive or unwanted step, resource, motion, etc.
•8 types of Muda
– Defects - Waiting
– Overproduction - Transportation
– Motion - Over processing
– Resources (Inventory) - Under utilization

24. Kaizen Training
24
Some examples NVA Activities:
Walking
Waiting on test
results
Transporting parts
Generating useless
reports
THE GOAL IS TO ELIMINATE THETHE GOAL IS TO ELIMINATE THE
NON-VALUE ADDED ACTIVITIES.NON-VALUE ADDED ACTIVITIES.
Unnecessary
motion
Unnecessary stock
on hand

25. To determine if a process step or
activity is VA, NVE or NVA….
Ask:
If we stop doing _____task, would our end customer
(patient) care?
If “YES”, then it is Value Added (VA)
If we stop doing ____task, would our internal customers
or key stakeholders (Physicians, nurses, administration,
regulatory agencies, etc.) care?
If “YES”, then it is Non Value Added Essential (NVE)
If the answer to both of these question is “No”, then
it is Muda (Waste / NVA)

26. Kaizen Event Phases
PLAN
• Business
Case Metrics
• Scope
• Executive
Sponsor
• Event Owner
• Team Leader
PREP
• Observe Work /
Flow
• Lean Tools
• Team Members
• Support
Functions
• Process Metrics
• Finalize
Business Case
Metrics
• Approvals
EVENT
• Business Case
• Training
• Current State
• Future State
• Test /
Implement
• Action Plan
• Communication
Plan
• Metrics
FOLLOW-UP
• 30/60/90
Day Plan
• Daily Mgmt
• Gemba
Walks
• Measure
Impact
I II III IV

27. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

28. Scale for rating each
criteria
0 if there is no impact
1 for low correlation
3 for medium correlation
9 for a high correlation

29. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

30. Pre-Event Preparation
1.Describe the opportunity
A. Stakeholder analysis
B. Define scope
C. Planning
2.Team selection and training
3. Have your targets set
4. Select Team leader
5.Set event objectives tied to your company’s
goals
6. Complete Kaizen Event Charter

31. Lean Six Sigma Project Charter
Title: Reduce Scrapped Cookies in NW Region BB/GB: B. Thornton
Business Gap
Defects & Metrics
Problem Statement
Team: B. Thornton (BB), A Yamoto (Process Owner), W.
Houston (SME), P. Smith (SME), G. Hines (SME), L. David (SME)
Champion: T. Wong
Project Scope/Boundaries:
Process Start: Mix Ingredients
Process Stop: Bake Cookies
In Scope: Chocolate Chip Cookies in all NW Bakeries
Out of Scope: Packaging
Milestones/Timeline: Scheduled Actual
Define Tollgate Review: June 4, 2007 6-4-07
Measure Tollgate Review: July 9, 2007
Analyze Tollgate Review: August 13, 2007
Improve Tollgate Review: September 10, 2007
Control Tollgate Review: September 24, 2007
Customer
Objective Statement
Our bakeries scrap approximately 25% of all cookies baked.
Scrapped cookies limit our ability to remain profitable while we
are being pressured to reduce prices by our competitors.
Scrapped cookies have always been an issue and it has
become worse since new ovens were installed. Based on a
Pareto Analysis we will focus initially on the NW Region.
External: Grocery Stores, Consumer
Internal: Regional General Manager
Defects: Scrapped Cookies
Primary: Scrap Rate for Cracked Chocolate Chip Cookies
(CCCC)
Secondary: Returns dues to CCCC’s
Consequential: Taste, Chewiness
The scrap rate due to cracked chocolate chip cookies
in the NW bakeries was 15% for the past 12 months
based on daily scrap reports.
Reduce the scrap rate due to cracks from 15% to 8% by
11/12/07 as measured by the daily scrap report
Financial Impact
$204,400 in direct savings based on current production rates
© BMGI. Except as may be expressly authorized by a written license agreement signed by BMGI, no portion may be altered, rewritten, edited, modified or used to create any derivative works.

32. Problem vs. Goal Statement
The purpose of the Problem Statement is
to describe what is Wrong
The Goal Statement defines the Team’s
Improvement Objective

33. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

34. Forming a Kaizen Team
Team member considerations:
• Effective problem solvers
• Team players
• Open minded
• Be aware of:
– CAVE

35. Kaizen Teams
Skeptics vs. Critics (CAVE)Skeptics vs. Critics (CAVE)

36. Kaizen Training
36
Steps on Team Development
FormingForming This is the development of a multi-functional
team with a variation of backgrounds and
knowledge
NormingNorming Stage where the group agrees how to
operate as a team
StormingStorming Open & honest discussion, also brainstorming
PerformingPerforming Agreement on solutions & taking action
AdjourningAdjourning Closing on the continuous improvement
process after 30 days

37. Document Reality
37
Kaizen NewspaperKaizen Newspaper
Add problem when youAdd problem when you
find themfind them
Responsibility listResponsibility list
Due dates forDue dates for
completioncompletion
Use as a to-do list during eventUse as a to-do list during event

38. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

39. Go to the
Gemba
Managers
Must Not Must Do
Give Up
Flex
Muscles
Throw Fits
Blame the
workers
Blame the
measures
Show boat
Cover
Up
Game the
measures
Throw people
at problems
Stress out
Hide in
the office
Create smoke
screens
Grovel Be clueless
Think of at
least 7 ways
to do better
Kaizen your
standard work
Observe the process
Find the waste
Have a vision
Provide the
right tools
Set goals
Communicate
direction39

40. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

41. LEAN EXAMPLE
START

42. Document Reality
Verify how are the processes done todayVerify how are the processes done today
– What’s really happeningWhat’s really happening
– See it for yourself (Walk the Gemba)See it for yourself (Walk the Gemba)
– Target sheets, area profilesTarget sheets, area profiles
– 5S Audits, Safety Audit5S Audits, Safety Audit
How does it work todayHow does it work today
– Spaghetti Chart, Standard WorksheetSpaghetti Chart, Standard Worksheet
– Layouts, DocumentsLayouts, Documents
What happens in this processWhat happens in this process
– Photos, Time ObservationsPhotos, Time Observations

43. Document Reality

44. Circle of Work – Process Analysis
Circle of Work analysis is crucial
1)to establish your baseline for the Lean project and
2)quantify improvements after change have been implemented.
Key points to remember
•Make sure all key elements of the process are included and a
representative, reasonable time period observed
•Ensure the observer is familiar with the process and can identify
all activities
•Use observation for single workers, work sampling for multiple
workers and overall worker / equipment utilization

45. Spaghetti Chart
An important aspect of the Circle of Work analysis is to visually depict
the flow of work from the perspective of the worker and / or product.
The standard sequence of work chart, also know as the “Spaghetti”
chart, accomplishes this objective.
Key aspects of the Spaghetti Chart are:
•A diagram that shows the motion of the patient / family / caregiver /
supplies throughout the course of care.
•A visual representation of the amount of travel involved for an activity
to be completed and the number of locations involved
•A Spaghetti chart will include the total distance traveled (in feet)
•Spaghetti charts are created BEFORE and AFTER improvements are
made in order to document success.

46. Document Reality
Standard Work SheetStandard Work Sheet
(Spaghetti Chart)(Spaghetti Chart)
• Operator path in RED
• Material path in BLUE
• Safety YELLOW
• Quality GREEN
46
Be consistent with colors and symbolsBe consistent with colors and symbols

47. Kaizen Training
47
What is TAKT Time?
TAKT is used to “set the pace” of the operation such that
it takes place at the rate at which the customer “PULLS”
from you.
By determining TAKT, you can adjust your offerings so as
to add or reduce capacity.

48. Kaizen Training
48
Single Piece Flow
Single piece flow is the basis of TAKT time
Single piece flow: Completing the process from start to
finish continuously
Batch Process Single Piece Flow
How many do you have? You have only one.
Where are they in the process? You know where it occurred.
What is the root cause? Resolve the root cause immediately.
The next process step is the customer…….
…..never send defects!!

49. Kaizen Training 49
TAKT Time Calculation
Available Time (seconds) / Period
Total Units of Customer Demand / Period
TAKTTAKT
Available Time / Period (one shift):
Breaks - 2 @ 15 minutes
Shift Time ( 8 hrs. )
Total Time Available:
- 30 mins.
480 mins.
450 mins.
Units Required / Period (one shift):
10,500 Units Sold Monthly
21 Working shifts / month
or 27,000 secs.
500 Required units / shift
TAKT Time:TAKT Time:
27,000 secs / shift
500 units / shift
54 secs.

50. Kaizen Training
50
Line Balancing
By redistributing some of the tasks
in Step D to A, B, and C…
…we can easily identify our target for
Improvement. If we reduce the cumulative
cycle times for all the steps by 12
seconds, we can potentially reduce from
four steps to three.
Takt Time

51. Flow
Movement of patients / products, services
and information down the value stream.
Objective is a continuous flow as patient /
product, service and information is
transformed by continuously adding value.
Flow is created by eliminating queues and
stops, and improving process flexibility and
reliability.

52. Pull
End customer pulls product / transaction
through the value stream.
Each step pulls the product / transaction
when needed from the preceding step.
Only the amount required is taken.
No action is taken until the downstream
process initiates it.

53. Push vs. Pull
A Fundamental Lean Principle
Push Principle – Admitting or feeder units say:
“We have a patient and need a bed”
Pull Principle – Floor Nurse says:
“We have a bed and we need a patient”
We always seek to eliminate waste, establish
flow and create a pull system

54. 5S System and Visual Management
Maintain and improve sort, set-in-order, shine, and
standardize
SortSort Separate the needed items from the un-needed items which
are then removed to a "red-tagged" location
Set InSet In
OrderOrder
Arrange remaining items in the way in which they will be
used
ShineShine
Maintain the work area for the already sorted and set-in-
order items
StandardizeStandardize Ensure sort, set-in-order, and shine are consistently
followed across all users
SustainSustain
5S5S

55. Sort
When in doubt, remove it!
• Segregate what is needed and what is not needed, discard what
is not needed.
• Use “Red Tags” to make it easy to reduce clutter.
• Note that “remove” does not mean dispose of. Unneeded items
that may have some value are moved to a holding area for
disposition.
STEP 1: Clarify what is needed.
STEP 2: Dispose of things that are not
needed.
STEP 3: With items that are needed,
segregate according to
frequency of use.

56. Set in Order
A place for everything, and everything in its place.
• Clearly mark and arrange everything neatly so what is needed can
be easily found.
• With unnecessary clutter removed, the team determines
appropriate locations for items that are needed to “add value”.
• After repositioning items and tools, the team applies temporary
labels, signboards, and positions.
STEP 1: Decide place for storage
STEP 2: Set up markings (Boundary Lines)
for storage locations
STEP 3: Mark items to be placed for storage
STEP 4: Use ingenuity to make maintenance
easy

57. Shine
Clean to inspect, inspect to detect, and detect to correct.
• Clean up personal and working environment so there are no areas
untidy with dirt or other clutter.
• Top to bottom cleaning and inspection.
• By touching and observing equipment as they clean, team members
can spot early signs of trouble before they cause break downs,
accidents, and defects.
STEP 1: Conduct overall ‘Shining’
STEP 2: Maintain cleanliness
STEP 3: Improvement plans to prevent dirtiness
STEP 4: Efficiency plan for sustained improvement

58. Standardize
You can see the perfection !
• Maintain the conditions of Sort, Set-in-Order, and
Shine
• Turn proven temporary methods for keeping the work
place uncluttered into permanent “VISUAL” methods
that make new standards obvious to everyone.

59. Sustain
Sustain the Gain. Pride of ownership!
• Adhere faithfully to the decisions that have been
made.
• Communicate and maintain practical approaches for
improved workplace conditions.
• Spread the activities and pride of ownership to all
levels and areas of the company.

60. What is Visual Control?
• The visual control method is based on the
5-S System
• Order is established with visual control
• Because it impacts us directly, a visual
control is considered aggressive in its
approach to adherence
• Visual controls can be very important as a
tool for error proofing and should always
be considered in a brainstorming effort

61. Examples of Visuals
Status
Board
Work Group
Display Boards
OR in Use
Prep Next Patient
OR Ready
Indicator Lights
Direction of Flow
Indicators
Gages showing
Normal
Operating Range
Fluid Markings
Process
Control
Boards
Color Coding of Patients

62. Standards not followed are not standards.
the lean proverbs

63. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

64. Waste can multiply itself like rabbits.
the lean proverbs

65. Identify Waste
• Remember the 8 Wastes
– Anything that doesn’t add value to the
customer
• Once identified make sure event scope is
correct
– Ok to change, make sure everyone knows
65

66. 5 Whys
• When problems are found
– Find the root cause by using the 5 whys

67. Asking why opens the mind to new causes.
the lean proverbs

68. Countermeasures
• Solutions need to be
implemented during
the week
• Try it out – action
versus analysis
• Creativity before
capital
• Continuous strive to
reduce waste, no
matter how small it is
• Attack items that
impact
– Process flow
– Material flow
– Information flow
• Solutions strive for
– Takt
– Flow
– Pull
– Lower Inventory

69. Kaizen
• Just do it!
– Action over analysis
• Improving specific piece
– The Value Stream
– Company goal
• Manage to completion

70. Spirit of Creativity - A
“McGyver” Capability

71. Symptoms to solve is little to resolve.
the lean proverbs

72. Section Review
• Value
• 8 types of Waste
• Kaizen Process
• Problem Statement
• Selecting Team
• Process Mapping – Spaghetti Map
• Takt Time
• Single Piece Flow
• Push vs. Pull
• 5S
• 5 Why’s

73. Break-out
Simulation

74. Simulation Round 2
• Run for 5 minutes
• Colors must be applied in sequence – first
Red, then Green, Orange, Blue, and Yellow
• You may redesign the work layout – you will
have 10 minutes to do this. Work layout
changes must be approved by a VP.
Flipchart your changes to facilitate approval
by a VP
• You may not change the job descriptions of
any of the process workers

75. Report Out

76. Examples of Set-up / Changeover
Activities
There are numerous examples of set-up / changeover activity in
healthcare, primarily for procedures and treatments:
•Starting / Removing IVs for patients
•Transporting patients in and out of rooms
•Verifying MD orders
•Staff understanding what procedure needs to be done and how
to do it
•Placing/securing/aligning patients on a table/bed and then
removing them
•Ensuring supplies and instruments are available and ready
before procedure or treatment begins
•Equipment readiness
•Interviewing patients regarding H&P information

77. Reducing Set-up Time
Set-ups are categorized in four phases
•Preparation
•Change / loading or unloading
•Adjustment / Alignment
•Inspecting and / or securing
Set-up reduction minimizes the amount
NVA time devoted to these activities

78. Set-Up Reduction
As previously indicated, the set-up / changeover would include:
•Any preparation
•Tearing down or cleanup of previous job, patient, procedure, etc.
•Searching for equipment, supplies, information
•Moving/transporting
•Testing/calibrating equipment
•Performing trial runs
•Making further adjustments
Setup
Finish
“A”
- - - - - - -
“A”
Begin
“B”
- - - - - - -
“B”
Set-up time is the time from the last step of the previous
item, service or run to the first step of the next.

79. Process for Set-up Reduction Analysis
The process for analyzing set-up (or changeover) reduction analysis
is as follows:
1.Identify all tasks associated with the set-up or changeover
2.Classify activities as happening while a process
3.Record the time associated with set-up activities
4.Associate all tasks with the four categories previously stated –
preparation, changeover (loading/unloading), adjustment/alignment,
inspection or securing
5.Brainstorm ideas to eliminate NVA time (i.e., maximize room or
equipment utilization) and minimize overall set-up activity
6.Quantify the improvements
7.Develop new standard work (SOPs) for the implemented changes

80. Set-up / Changeover
Improvement Ideas
When examining the categories of set-up / changeover (preparation,
changing, adjusting, secure/inspect), there are several common flags
or opportunities to look for:
•Alignment / Adjustment time: any type of alignment or adjustment
of patients or equipment should automatically be considered a flag for
evaluation, since they are typically non-valued added tasks. Analysis
of equipment options (e.g. guide pins, blocks, scales) or some 5S type
controls for patients could provide viable solutions.
•Securing / Inspection time: regarding equipment, consider available
options (e.g. Velcro vs. screw type restraints), while with patients
evaluate repeatable or duplicative tasks (tests, vital signs, etc.).
Multiple approvals or assessments should also be evaluated.
The goal should be to maximize room
and/or equipment utilization.

81. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

82. Make Changes
• Make the changes – NOW!
– Don’t get stuck waiting for a better time
– Make the changes then observe them
• Pre-plan for large moves before the
event
• Everyone needs to contribute
– Don’t dictate, build teamwork
• Make sure you update the newspaper

83. Verify Changes
• Verify with new observations
• If it’s not easier, make more changes
• Goal is to put new process in place and
verify it
– Do this early in event to allow time for more
changes
– Make sure a better process is working at end
of event

84. Kaizen Process
• Selecting Projects
• Setting Goals
• The Team Leader and Team
• Support and Infrastructure
• The Kaizen Blitz Steps
– Set the scene (Document current reality)
– Observe the current process (ID waste and
countermeasures)
– Develop the future state process
– Implement the new process (Make & Verify changes)
– Report and analyze (Measure results, Create new
standard work)
• Potential Roadblocks

85. Kanban Definition
A Japanese work that means “signboard”
•In a Lean enterprise, it’s a signal authorizing production or delivery of
required materials. The signal is initiated by consumption from an
upstream process
•Allows a just-in-time (JIT) environment to be set up but it requires:
– Level Production
– Pull
– Defect Free Products
•A Kanban is a high-level tool that is implemented after solving many
problems
Kanbans route information in a pull system
Supermarkets provide material for a pull system

86. Measure Results
• Compare results with baseline data
– Did we make it better?
– Was waste removed?
• Did we achieve what we wanted to?
Not all changes are successful.Not all changes are successful.
Don’t worry.Don’t worry.
Learn from what we’ve done!Learn from what we’ve done!

87. Improvement Idea
Date: __________
Kaizen Title:____________________ Team #: ____________ Completed By: __________________________
Description of Problem: Description of steps taken: Results:
Before Kaizen After Kaizen
Remarks:
The lift truck cords were
continually being left on the floor
causing delays and damage.
A cord retractor was
installed at each recharge
station.
Prevents
damage to
plugs
Eliminated
trip hazard
87

88. Single Point Lesson
Water cooling lines
• Mistake proofed fittings
• Hoses can only be hooked up one way
– Simple fix, no money spent, just switched fitting from
hose to fixture
88

89. Mistake proofed is mistake’s pain missed.
the lean proverbs

90. Section Review
• Reducing Set up Times
• Making Changes
• Verifying Changes
• Kanban
• Measuring data

91. Break-out
Simulation

92. Simulation Round 3
• Run for 5 minutes
• Colors must be applied in sequence – first
Red, then Green, Orange, Blue, and Yellow
• You may not change the job descriptions of
any of the process workers
• The Department Director has decided to
institute a Kanban system. The VP or
facilitator will explain Kanban
• In your group, apply the concepts of Set-Up
Reductions

93. Report Out

94. Create New Standard
• Put new visual standard work in place
– Maintain progress made during event
– Training tool
– Should be understood by anyone observing the process
• Post all open action item on the Kaizen Newspaper
– Make sure all items have a name attached to them
– Follow up to make sure they get completed
• Visually display what has happened in the area
• New process must be repeatable and sustainable
– Try it out during the week!!!
Celebrate

95. Standard Work
What is “Standard Work”?
•For a given process, it is having every activity done in the same sequence and
manner every time with the least possible amount of time in order to meet
customer specifications. It is the most effective combination of activities that
will minimize non-value-added activities while providing the highest quality of
care.
•For the process workers, it is knowing what to do, how to do it, and when to do
it every time the process cycle occurs
•For the process non-labor, it is having the right supplies and equipment
available when they are needed and in the right quantity (Just-In-Time).
Without standard work, there can be no continuous
improvement - it is the basis for Lean transformation

96. Standard Work – Healthcare
Examples
• Clinical pathways, protocols, practice guidelines for
disease state or DRG management
• Standard Operating Procedures(s) for a treatment or
case, including patient prep and discharge
• Organizational Policy and Procedures – departmental or
hospital wide
While we can see from the above that standard work has
existed to some degree in healthcare (but not
necessarily successfully), it is not even remotely close
to where it needs to be for us to meet the challenges
in the years ahead

97. Standard Work – Critical
Components
Implementation of Standard Work involves five steps,
all of which incorporate numerous lean tools. The five
steps are:
•Evaluate the current situation
•Identify areas of opportunity
•Modify the existing process
•Substantiate and enumerate improvements
•Implement the new standard work

98. Standard Work - Evaluation
Evaluating the current situation of the process will
involve the use of several tools discussed thus far:
•Observation – time value analysis (TVA). Note times,
dates, and any specific circumstances involved with
the observation
•Spaghetti diagrams
•Forms – time observation sheet
•Determine current line balance of the process (Takt
time of the process applied for each process step).

99. Standard Work – Identify Opportunities
Examples of the 8 Wastes:
Defects: Medication errors, wrong site surgery
Over Production: Preparing IV’s ahead of time
Transportation: Transporting lab specimens, patients
Waiting: Waiting for bed assignments, treatments,
discharge orders
Inventory: Lab specimens, supplies
Motion: Searching for charts / supplies
Processing extra: Excessive paperwork, unnecessary tests, using IV
over oral meds
Under-utilization: RNs doing non clinical paperwork; CPAs doing
basic G/L work, idle equipment

100. Standard Work – Modify the
Process
In this step, Lean tools are employed to
change the process and make improvements:
•Brainstorming
•5S
•Visual controls, indicators, signals,
guarantees
•Line Balancing
•Leveling
•Quick changeover – setup reduction

101. Standard Work – Piloting Process
Attempt to conduct a pilot of the process changes
first before full implementation in order to
demonstrate the feasibility and success of the
changes
In a Lean Kaizen event, this is normally the
“Trystorming” phase. This occurs quickly in the
process, and team participants will in real time make
whatever changes are needed based upon feedback
from workers in the process.
If a pilot cannot be conducted and full
implementation is required for the process, ensure
that careful monitoring exists and that changes can
be made to the new process if warranted.

102. Standard Work – Implement New
Standard
In order to fully implement new standard work for a
process, the following steps need to be taken:
•Training of all personnel affected by the changes must
take place through formal verbal communication and
written documentation. Install as many visual
indicators, signals, or controls as possible to help
facilitate understanding and compliance.
•Objective, quantifiable measures (if not done
previously in the project or Kaizen) must be created to
monitor worker compliance and to determine if
improvement is continuing to occur. Monthly or
quarterly reports to management should be a norm.

103. Error - Proofing
A technique for eliminating errors
Making it impossible to make mistakes
In Japan: Poka-Yoke. Poka means an inadvertent
mistake. Yoke means to prevent
It is good to do it right the first time: it is even
better to make it impossible to do it wrong the
first time.

104. Poke Yoke
Poke-Yoke (pronounced Po-Ka Yo-kay) – stands for
mistake –proofing
Usually the physical alteration of a devise or process so
as to guarantee only one way (the right way) to carry
out a task.
•Electrical sockets – only one way to plug in
•Petrol vs. diesel spouts at a gas station – a diesel
nozzle will not fit into a petrol gas tank
Medical examples of Poke-Yoke:
•Anesthesia gas equipment – port valves only designed
for correct gas tubing (e.g. oxygen tubes can only fit on
oxygen ports of the anesthesia equipment)

105. Error-Proofing Techniques
Technique Prevention Detection
Control
(Shut Down)
An error is
impossible
Defective item can’t move on
to the next step
Warning An error is about to
be made
An error has been made
Errors may either be prevented or detected

106. Why Do Errors Occur?
• Incorrect or non-existent procedures
• Overly complex processes
• Excessive variation in the process
• Excessive variation in the inputs
• Inaccurate measuring system
• Human error

107. Human Error Provoking
Conditions
1. Adjustments
2. Unclear or no instructions
3. Undefined process
4. Many units/mixed units
5. Multiple steps
6. Infrequent production
7. Ineffective or lack of standards
8. Multiple handoffs
9. Hand processing
10. Rapid repetition
11. High volume demand or deadline pressures
12. Environmental conditions
Robust processes reduce Human Errors!

108. Three Inspection Methods
• Traditional inspection (end of the process) – discovers defects
– Sort “good” from “bad” at the end of the process
– Measure “Y” into categories (good/bad)
• Informative inspection (during the process) – reduces defects
– Use process data to control/correct the process (e.g. Statistical
Process Control Charts)
– Measure “Y” for variables information to control “Y”
• Source inspection (before the process) – eliminates defects
– Inspect for error producing conditions in the process.
– Measure and control “X’s” to create good “Y’s”

109. 7 Steps to Error Proofing
1. Create a process map and identify the locations at which the
defects are found and made
2. Evaluate current procedures for adequacy and determine if they
are being followed
3. Identify defect provoking conditions at each process step
4. Identify the root cause(s) (error) of each type of defect and in
which process step it occurs (FMEA, 5 Whys, Cause & Effect
Diagram)
5. Identify the type of error-proofing device or process required
(Brainstorming)
6. Create the device or process and try it
7. Measure for effectiveness

110. Section Review
• Standard Work
• Error Proofing
• Poke Yoke
• Inspection Methods
• Visual Controls

111. Break-out
Simulation

112. Simulation Round 4
• Run for 5 minutes
• Colors must be applied in sequence – first Red, then Green,
Orange, Blue, and Yellow
• Great news! The hospital has gained such a reputation for
efficient and patient friendly operation that the department’s
volume is expected to increase sharply. Your VP will tell you what
volume you will need to handle during this round
• The Department Director recognizes that in order to meet the
increased demand without adding staff, the department will have
to operate more efficiently. She suggests that you may want to
make additional improvements by redesigning the job descriptions.
You will have 10 minutes to redesign the jobs, train everyone and
rearrange the work layout as needed to accommodate the new
roles.
• In your group, apply the concepts of Standard Work and error
proofing to your simulated process

113. Dot Exercise Debrief
• What are the “Lessons Learned”?
• Can you Apply these “Lessons Learned” to
your area?

114. Kaizen not maintained dissipates like smoke.
the lean proverbs

115. Lean Summary
• Linking value stream map, cycle time analysis and value
analysis creates a compelling business case for change
• Making the process visible highlights potential problems and
sources of variation
• Evaluate the flow through the operations to determine what
hinders the flow
• Use the best tools available to help identify solutions /
improvements (e.g., process maps, C&E diagrams,
brainstorming, etc.)
• The leveled schedule and process sequencing should allow
for the process flow to be paced according to customer
demand
• TAKT is used to set the pace of the process step
• Use Lean and Six Sigma tools in combination and / or alone
to solve your process problems

116. Websites
Performance Excellence Website (go live 8/20)
Free Lean Six Sigma & Kaizen forms / images:
www.bmgi.org http://www.youtube.com/watch?v=wfsRAZUnonIhttp://www.youtube.com/watch?v=lwWI-3z1wPull system
Total Productive
Maintenance
Total Preventive
Maintenance
Value stream analysis in
healthcare
Push system
Gemba kaizen Continuous Improvement Kanban and Pull systems Kanban
Lean kaizen Lean six sigma 5S Lean Visual Controls
Problem solving Value stream analysis 5S visual controls OEE
PEx Website
(Online 8/20)
http://inside.uams.edu/performance-excellence

117. The End
What questions do you have?