applying toyota lean principles in a healthcare supply chain partnering between supply chain &...
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Applying Toyota Lean Principles
in a Healthcare Supply Chain
Partnering between Supply Chain & Clinicians
WSHMMA Spokane 2006
Ken Fortune: Director of Purchasing & Distribution
Allen Caudle: VP Supply Chain Management
Swedish Health ServicesSeattle, Washington
Swedish Health ServicesSwedish Health Services
Largest Hospital System in the Pacific NorthwestLargest Hospital System in the Pacific Northwest 4 Acute Care Facilities4 Acute Care Facilities 25 City Blocks and 5.5 million Ft25 City Blocks and 5.5 million Ft22
1,286 Total Beds1,286 Total Beds Not for Profit – 501c3 OrganizationNot for Profit – 501c3 Organization Net Revenues - $1.1 billion (2006 budget)Net Revenues - $1.1 billion (2006 budget) 6,970 Employees6,970 Employees 1,744 Physicians1,744 Physicians 54 Operating Rooms54 Operating Rooms Approximately 40,000 Surgical ProceduresApproximately 40,000 Surgical Procedures $170M Total Supply Spending$170M Total Supply Spending
HospitalDivision
HospitalDivision
Home Health & Hospice
Home Health & Hospice
Physician Division
Physician Division
JointVenturesJoint
Ventures
FoundationsFoundations Research & Education
Research & Education MOBsMOBs
Supply Chain Vision Supply Chain Vision The Gold StandardThe Gold Standard
Supply Chain Vision Supply Chain Vision The Gold StandardThe Gold Standard
PatientCare
Med Surg SupplyImplementation RPI
Periop ServicesSupply Chain
Clin. Info System RPI Redesign
Nursing Unit Storeroom 5S
Bed Turnover RPIEnvironmental Services
Critical Use Equipment RPI
Pyxis
Treat the patient care constraint like Gold -- Align the organization and deliver The Gold Standard to our customers and clinical service partners!
Treat the patient care constraint like Gold -- Align the organization and deliver The Gold Standard to our customers and clinical service partners!
Forms Process Improvement RPI
What is the Toyota Production What is the Toyota Production System or “Lean Thinking?”System or “Lean Thinking?”
Request RevenueValue Stream Time Line
1. Value - define precisely what delights customers
2. Value Stream = Service Lines - identify all processes
3. Flow - make value steps flow by removing waste in every form
4. Just-in-Time - design & provide precisely what customers want precisely when they want it
5. Perfection - pursue through Daily Management
10 Leadership Practices for Managing 10 Leadership Practices for Managing & Sustaining Lean Operations& Sustaining Lean Operations
Establish a Good, Two-way Relationship
Goal Achievement
Set Context
Assign Tasks
Plan & Resource
Improve Work Continuously
Employee Development
Assess Judgment & Discretion
Coach & Develop Staff
Recognizing & Rewarding
Staff
Select & Orient Staff
Reassign, Correct
or Dismiss
•Quality•Patient
Satisfaction
•Lead-time
Success Requires 3 Stratum Success Requires 3 Stratum Leadership & Management Leadership & Management
Guidance TeamGuidance Team
DIR
Mgr
VP
COOCEO
VP
DIR
Mgr
DIR
Mgr
DIR
Mgr
Customer
Management Guidance Team• Epidemiology & Nursing• Cross-org. alignment -- BioMed, Envir. Services, Sterile Processing
3 Stratum Leadership• Authorizing manager• Process Manager• Experts in the Process
Our RPI Project Our RPI Project Management Process Process
ExecutiveCommitment
PLANRPI
Blueprint
60 DayReview
30 DayReview
WORKSHOPWEEK
DAILY MANAGEMENT(RPI Newspaper)
RPI
Hold the Gains
P
S
A
D
Sustainable Improvement
ASSESSMENTGo/No Go?
Activities of the Four Activities of the Four PhasesPhases
Initial Initial meetingmeeting
Process Process reviewreview
Site VisitSite VisitAssess Assess
managersmanagersFeedbackFeedback
- - OpportunitiesOpportunities- Risks- Risks- Scope- Scope
Go/No Go Go/No Go decisiondecision
Learn Learn toolstools
Analyze Analyze processprocess
Eliminate Eliminate wastewaste
ImplemenImplement short-t short-term term plansplans
Develop Develop follow-on follow-on plansplans
Complete Complete workshop workshop actionsactions
Implement Implement Daily Daily MgmtMgmt
Check Check results and results and hold gainshold gains
Spread to Spread to other areasother areas
Assessment
Workshop Workshop ObjectivesObjectives
Process Process boundariesboundaries
Timing setTiming setParticipant Participant
preparationpreparationManagemeManageme
nt nt preparationpreparation
Data Data collectioncollection
Agenda setAgenda set
Planning Workshop Daily Mgmt
Roles in the RPI Management Roles in the RPI Management Guidance TeamGuidance Team
Provide uninterrupted team member participation. Provide uninterrupted team member participation.
Remove barriers for the workshop participants. Remove barriers for the workshop participants.
Empower and support the workshop participants to Empower and support the workshop participants to implement changes (i.e. provide resources).implement changes (i.e. provide resources).
Notify and coach workshop participants for their Notify and coach workshop participants for their role in the workshoprole in the workshop
Participate with team to resolve issues and mediate Participate with team to resolve issues and mediate differences.differences.
Advocate for the need of customers and “the whole” Advocate for the need of customers and “the whole” vs. a particular unit of people. vs. a particular unit of people.
Take risks and encourage workshop participants to Take risks and encourage workshop participants to do the same.do the same.
Celebrate and congratulate the team on success.Celebrate and congratulate the team on success.
3 Actuals Walk3 Actuals Walk
““The time that provides me with the most The time that provides me with the most vital information about management is vital information about management is the time I spend in the plant, not in the the time I spend in the plant, not in the vice president’s office.” -- Taiichi Ohnovice president’s office.” -- Taiichi Ohno
Go to the Go to the Actual PlaceActual Place Talk to the Talk to the Actual PeopleActual People Observe the Observe the Actual ProcessActual Process
The 5S’sThe 5S’s
Sustain Hold the gains & improve.
Standardize Develop common methods for consistency.
Sweep Sweep to clean and visual sweep to understand.
Simplify A place for everything & everything in its place, clean & ready to use.
Sort Separate the needed from the not needed (waste).
Pre-RPI SDS Case Cart ProcessPre-RPI SDS Case Cart Process
Window (10)
PL MSC
ORSuite
SPD
PDC
Rx Room
SDSCore
Suture Board
2 WKS PLs = $90kCore (30%) = $30k
4 Turns3+ months
40 Different Inventory Locations
Q
Q
Q
Q
QQ(136k) (65k)
Packs, Supplies
Pick Tickets
Instruments, Packs,
Soft Goods
Medications
Supplies, Equip,
Instruments
Supplies
Suture
Q
New Case Cart Building Process
Inventory Supply Room
Pull soft goods for 1st case next day
– Andrew (day before)
Packs, Solutions, Canisters
Meds, Suture, Equipment
Soft Goods
Linen
Instrument Set
PDC Items
DOSPull clean cart into
inventory room.Put on soft goods and PDC items.
Back Hallway
Take cart to back hallway
Put on instrument set, solutions, custom pack,
canisters, linens and bags
Laundry
Linen exchange cart -
daily
SPDSPD pulls
instrument set for next day.
Take to SDS, w/PL’s, to Kanban
spot
MSC
MSC restock soft goods, custom pack, solutions,
canisters – daily
PDC
DOSPDC pull items; put
on cart; place in inventory room for
Andrew
Core
Facilitator gets equipment and
positioning devices
Facilitator pulls meds, saturns and MD sterile
specials
OR Suite
Push cart into OR for 1st case – TF cases, push into kanban square
Case Cart Building Case Cart Building Process FlowProcess Flow
DOS
At 6amDay Before DOS Before 6am
§ SPD brings up cart with instrument sets for 1st unit (4 hrs) to designated spot in clean side of decontam with a list of what goes where
§ Specialty instrument (non-stored) for each procedure are combined with the instrument set by SPD
§ PDC pulls items needed for entire day and places on cart
§ Cart is moved to back hallway of Core to designated spot
§ Case Cart Builder (CCB) gets clean cart from back hallway designated spot and takes to clean decontam
§ CCB puts instrument set, peel pack and un-sterile specials; and pushes to inventory storage room
§ Add designated tote
§ Push cart to back hallway
§ In back hallway, CCB adds solutions, canisters, linens, PDC items and custom packs
§ Case cart pushed into designated OR
§ 1st case only
§ Facilitator pulls sutures, meds, and sterile MD specials and peel pack items
§ Facilitator gets equipment and positioning devices
§ Pushes cart into OR when complete
§ Repeat steps 4-6 for next case
§ CCB places TF case cart in designated spot in back hallway or outside OR
Inventory Supply Room
§ Case cart builder pulls soft goods for 1st case of next day
§Places soft good in tote designated for specific OR
§ Stages for next day
Data SummaryData Summary # Steps# Steps 111111 4545 ↓ 59%↓ 59%
# VA Steps# VA Steps 6 6 6 6
# NVA Steps# NVA Steps 105105 3939 ↓ 63% ↓ 63%
# Queues# Queues 4 4 3 3 ↓ 25% ↓ 25%
# Handoffs# Handoffs 23 23 3 3 ↓ 87% ↓ 87%
# Feet Traveled# Feet Traveled 10,23410,234 378378 ↓ 96% ↓ 96%
# In Queue (WIP)# In Queue (WIP) HundredsHundreds
Lead TimeLead Time 58 Hrs58 Hrs 17 Hrs17 Hrs ↓71%↓71%
Cycle TimeCycle Time 8 Hrs8 Hrs 15 min15 min ↓ 97%↓ 97%
SpaceSpace C FloorC Floor
B FloorB Floor
A FloorA Floor
Inventory ReductionInventory Reduction Patient ChargeablesPatient Chargeables BeforeBefore FutureFuture ChangeChange SDS CoreSDS Core 7,944 7,944 7,378 7,378 SPDSPD 5,394 5,394 0 0
$ 13,338$ 13,338 $ 7,378$ 7,378$ 5,960$ 5,960
Non-ChargeablesNon-Chargeables SDS Core & Inventory SDS Core & Inventory
RoomRoom 19,498 19,498 2,765 2,765 SPDSPD 2,169 2,169 0 0
$21,667$21,667 $ 2,765$ 2,765$18,902$18,902
Returns to MSCReturns to MSC $ 2,000$ 2,000
SutureSuture SDS CoreSDS Core $ 65,119$ 65,119 Marked boxesMarked boxes $ $
9,896 9,896
TotalTotal $36,758$36,758
Percent of SDS Average Weekly Stockouts
0.45%
0.27%
0.22%
0.72%
1.08%
0.81%
0.36%
0.60%
0.36%
0.65%0.58%0.58%0.72%
0.00%0.00%
0.22%
0.00%
0.29%0.45%
0.14%
0.58%
1.01%
1.22%
0.58%
JULY – DECEMBER 2005PERCENT OF SDS AVERAGE WEEKLY STOCKOUTS
Percent of MSC Average Weekly Stockouts
3.29%
2.97%
2.39%
2.71%
3.57%
3.19%
3.07%2.99%
2.90%
3.17%3.08%
3.03%2.95%2.94%
2.64%2.57%
2.50%
1.89%
2.15%
1.85%
2.39%
2.65%
2.57%
3.21%
2.64%
JULY – DECEMBER 2005 PERCENT OF MSC AVERAGE WEEKLY STOCKOUTS
Communications & Instrument Delivery ProtocolCommunications & Instrument Delivery Protocol
Pick instruments and record missing instruments
(Blue Sheet)
2nd Shift
2nd Shift prints pick tickets after 5p
Sort pick tickets intotwo piles
1st Shift
7:30a – 12:30p1st run pick tickets
No front sheet
Copy Missing Instrument Sheet
Send copy w/instruments
Place original w/1st shift pick tickets
Deliver instruments for the day to SDS by 11:30p
SPD calls SDS for Missing Instrument Needs #66042 at
6:00a
12:31p – 5:31p1st Shift
Pick instruments and record missing instruments
(Blue Sheet)
Copy Missing Instrument Sheet
Send copy w/instruments
Deliver instruments to SDS 10:00a
Dispose used PL’s
Call SDS for Missing Instruments #66042 by 11a
Dispose used PL’s
Rapid Instrument Turnover Flow SDSRapid Instrument Turnover Flow SDS Circulating RN calls for
instruments to be picked up in OR
Instrument suitable for auto wash?
Hand wash
Initial cleaning by hand
Run in washer
Deliver to room
Deliver back to room
Sterilize
Time available to auto wash
Sterilize
Hand washDeliver back
to roomSterilize
No
No
Yes
Yes
Forms “System”
Form content is developed
Someone wants to generate or revise clinical protocol, careplan, clinical guideline or other clinical
form
Stakeholder Approval
Process for Implementati
on
Print Process
Forms Committee and Standards
Committee Approval
Processes
NO
Approved?
YES
Track form
Track form
Track form
Track form
Track form
Printed Forms
Storage/Inventory(Merrill, MSC, 1 SE)
Department/Unit
Sort & PurgeOld Forms
To DepartmentsTo Inventory/Storage
Swedish On-line forms and orders
Sort & PurgeOld Forms
Track form
Management and Storage of Forms and Forms Inventory In The Units and In All Storage Locations
Goals:Ø Reduce staff “search time” for forms
Ø Identify and inventory most current forms
Ø Find opportunities for standardizing forms process on units
Ø Eliminate forms that are problematic for patient safety
Ø Reduce forms inventory on units, MSC, Merrill
Ø Identify responsible person to manage forms inventory on unit
Ø Design staff education format for new/improved forms process in units
Ø Design process so that nursing units are aware of when a new or revised form is in house and how to obtain it on the unit
Ø Design process so that prior to distribution of new or revised forms, staff have received notification and or education as appropriate
Ø Identify who pays for purged/discarded forms
Ø Standardize process to notify MSC and Merrill when form has been discontinued
Ø Standardize process to notify MSC and Merrill for just-in-time delivery of forms to unit
Storage/Inventory
Storage/Inventory(Merrill, MSC, 1 SE)
Department/Unit
Department/Unit
Sort & PurgeOld Forms
Sort & PurgeOld Forms
Printed Forms
Forms Development Process
Form content is developed
Someone wants to generate or revise clinical protocol, careplan, clinical guideline or other
clinical form
Stakeholder Approval Process for Implementation
Print Process
Forms Committee and Standards Committee Approval Processes
PDSATeam meetingsStakeholder inputEvidence-based researchPilot/Test in daily workMake recommended revisionsPut into standardized formatBegin form education plan Prepare to submit to Forms and Standards CommitteesTrack through Committees’ processesRevise as Committees requireResubmit to Committees for approval
Submit to key stakeholder committees and councilsMake revisions if necessaryResubmit to project team for rework if necessaryResubmit to Forms and Standards if necessarySubmit to Print process when final
NO
Approved?
YES
Track form
Track form
Track form
Track form
Track form
Forms have been printed
To Management After Printing Process
GOALS
· Reduce lead time for forms development and printing
· Streamline and standardize forms development process
· Design staff education format for new/revised forms
· Reduce cost of forms development and printing
· Link Forms and Standards committees to the Forms Development Process
· Identify single point accountability for Forms Development Process
· User can track forms development process
· Prepare for the transition of forms to CIS
Swedish On-line forms and orders
Track form
Becoming PartnersBecoming Partners
The week-long Rapid The week-long Rapid Improvement Process Workshop Improvement Process Workshop helped to break down long-helped to break down long-standing barriers between standing barriers between departments…departments…
Surgery was unaware of the Surgery was unaware of the services Supply Chain could services Supply Chain could provide to them…provide to them…
Communications opened up Communications opened up during the workshop with many during the workshop with many opportunitiesopportunities
Becoming PartnersBecoming Partners
The RPI was a strong success…The RPI was a strong success…85% reduction in “Go-Gets” by 85% reduction in “Go-Gets” by moving supplies closer to point moving supplies closer to point of use and case cart accuracy of use and case cart accuracy improved to 99% because cases improved to 99% because cases picked within core and on a just-picked within core and on a just-in-time basis.in-time basis.
Right people, doing right job, at Right people, doing right job, at the right timethe right time
SummarySummaryHOW HAVE OUR ROLES CHANGED?HOW HAVE OUR ROLES CHANGED?
• Better partners between Supply Chain Better partners between Supply Chain and cliniciansand clinicians
• Supply Chain viewed as professionals Supply Chain viewed as professionals in supply management and leaders of in supply management and leaders of sustained process improvementsustained process improvement
• Supply problems eased in the OR with Supply problems eased in the OR with better supply management process better supply management process (fewer stock outs and “go-gets” from (fewer stock outs and “go-gets” from the rooms)the rooms)
• Nurses can be nurses – focusing on Nurses can be nurses – focusing on patient carepatient care
HOW HAVE OUR ROLES CHANGED?HOW HAVE OUR ROLES CHANGED?
• Supply chain professionals Supply chain professionals manage the process with data manage the process with data and continued “Roundings” and continued “Roundings” with clinicians, OR managers, with clinicians, OR managers, and physiciansand physicians
• Supply chain professionals Supply chain professionals are now relied upon to solve are now relied upon to solve other problems in the ORother problems in the OR