A primer for healthcare leaders about Lean / process improvement.

1. Gemba Walk:
Starting your Lean Journey
Brian Ramos, MBA
Director of Practice Operations
Plexus Management Group, Inc.
© 2013

2. Abstract & Learning Objectives
Abstract:
Made famous by the Toyota Motor Corporation, Lean has been effectively used
in the healthcare industry for over a decade. However, most healthcare
professionals have not been exposed to the management philosophy. This
introductory presentation will help participants understand Lean’s applicability
and use in our field and learn how to identify and eliminate waste in each
process in their clinical or business unit.
Learning Objectives:
1. Understand the core principles of Lean thinking.
2. Understand the process of value stream mapping and its use in Lean.
3. Learn how to identify and eliminate waste (“muda”) in your practice’s
current processes.
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3. Let’s start at the end . . .
• What have you heard about Lean?
• Is Lean mean?
• Is it all about the bottom line? Reduce staffing?
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4. Lean in Healthcare
© 2013 N.B. List is not exhaustive

5. Reasons for Action
• Economic environment cannot sustain current
health care cost structure.
Source: USA Inc.: Red, White, and Very Blue, Forbes Magazine, February 24, 2011
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6. Reasons for Action Continued
• Patients as Consumers
– Choice
• Quality & Safety
– Wide variation in quality measures and outcomes across
institutions and patient populations.
– Despite spending more than any other country (17.6%
GDP), the US ranked:
• 39th for infant mortality
• 43rd for adult female mortality
• 42nd for adult male mortality
• 36th for life expectancy
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7. Core Principles
1. Respect for People
 Employees know work best
 NOT top-down approach
2. Continuous Improvement
 Strive for zero defects
3. Customers (i.e. patients)
define value
4. Based on the scientific
method (e.g. experimentation)
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8. Value Stream Mapping
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9. Value Stream Mapping Identifies Waste
Value Added Non-Value Added
Any activity that directly Any activity that consumes time or
contributes to satisfying the needs resources but does not add value.
of a customer.
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10. 8 Wastes in Healthcare
TRANSPORTING WAITING
Moving anything on wheels (e.g. patients, Patients in a waiting room; waiting for lab
specimens, equipment or supplies) results
INVENTORY OVERPROCESSING
Stock of medical or operational supplies, Asking patients for their information more
patients in beds, specimens waiting for analysis than once; ordering more labs than needed
MOTION OVERPRODUCTION
People reaching, bending, or searching for Creating forms “just in case” you need them;
supplies, patients, other staff producing more labs than needed
HUMAN TALENT DEFECTS
Unused or untapped potential of staff Wrong patient, wrong procedure, redraws
What are some examples of waste in your practice?
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11. Examples of Waste
• Underutilized ORs • Wrong-site surgery accounts
for 13% of medical errors.
Waste
(excess capacity)
Source: injuryboard.com
• Waiting for:
– Provider
– Patient
– Results
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12. Everyday Lean
Tools you can use right now to do “Lean Lite”
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13. Daily Huddle
• Ensure team communications
• Opportunity to prevent issues from developing
• Focuses on small, incremental, change/improvements
• Same time, every day, for NO MORE than 5 minutes
• Everyone attends! That means doctors, mid-levels, nurses too!
• Initiated by manager, eventually led by all team members.
• Stand-up! (preferably at a visual management board)
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14. Visual Management
 Balanced scorecard
approach.
 People
 Quality/Safety
 Delivery
 Cost
 Growth
 Set goals by
“doubling the good
and halving the bad”
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15. Visual Management Continued
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16. Standard Work
• current best known way to perform a task
• Standard work secures improvement
• Encourages root cause problem solving vs. firefighting
• Do you use checklists? They’re a type of Standard Work
Lean
Principles
Performance
STD WORK
Time
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17. Pareto Analysis
 A means of focusing “80/20 Rule”
on areas that matter
the most
 Bar chart showing the
affect of different
categories of a given
problem
Benefits:
 Avoid working on the
wrong or insignificant
problem.
 Speaking with data
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18. PICK Chart
• Identify actions then group into benefit and
difficulty
High
• P Plan to Do 6 4 1
• High benefit, Make a plan how to 2
I P9
do it.
BENEFIT
7
• I Implement
• High Benefit, Easy to Do. C
Implement Now K5
Low
3 8
• C Choose (which if any) To Do
Low High
• Low benefit, but easy to do. DIFFICULTY
• K Kick Out
• Low benefit and difficult to do.
Don’t bother with these!
Do the high benefit/low difficulty actions.
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19. 5 Whys
• The easiest of all Lean “tools”
• Ask “why?” five times to arrive at the root cause
.
• A patient broke his leg in our clinic today.
Why?
• Because he fell
Why?
• Because the floor was wet
Why?
• Because there was a leak from the water fountain
Why?
• Because the valve seal was broken
Why?
• Because the fountain had not been maintained.
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20. Success Story
Ambulatory Endoscopy Suite
• Staggered Patient Arrival Times Wait Time
RN Overtime Pay
• Gastroenterologist dictated note in Wait Time
EMR in procedure room Motion
• Increased through-put by 20% in each
procedure room. Revenue
• Maintained 99% patient satisfaction
scores on Press Ganey survey.
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21. Recommended Reading
Websites:
 PBS Healthcare Cost Comparison
http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-
compares-with-other-countries.html
 Lean Enterprise Institute http://www.lean.org/
 Virginia Mason Institute http://www.virginiamasoninstitute.org
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22. Questions & Answers
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23. About the presenter
Brian Ramos is an accomplished healthcare executive who is passionate
about eliminating waste and lowering the cost of healthcare delivery
systems. He has successfully created profitable clinical units in academic
medical institutions, large private physician practices, and ambulatory
surgical centers. Brian was formally trained in the Toyota Production
System (Lean) and uses these tools to create cultures of continuous
improvement.
He serves as the Director of Practice Operations for Plexus Management
Group, a healthcare management services organization and consulting
firm in the greater Boston area. In his role, Brian provides chief operating
officer functional responsibility to client ambulatory practices including
Brian Ramos, MBA
Director of Practice Operations P&L oversight, leadership of office-based practice administrators, and
development of client strategic plans and partnerships.
Plexus Management Group, Inc.
690 Canon Street | Suite 325 Brian earned a master's degree in Business Administration from
Westwood, MA 02090 Fitchburg State University and a bachelor’s degree in Mathematics &
Computer Science from Boston College. He is a Certified Medical
bramos@plexusmg.com
ph. 781.407.7771 Practice Executive (CMPE) nominee of the American College of Medical
Practice Executives. Additionally, Brian holds Lean Silver Certification
from Simpler® Healthcare.
Follow me:
Disclosure & Attestation
@brianmramos The speaker attests that he does not have any real or apparent financial relationships or
commercial interests to disclose.
© 2013