The “Low Down” on Lean

Bonnie Brossart, CEO, Health Quality CouncilDebra Jane Wright, Executive Director, Learning and Implementation,

Provincial Kaizen Promotion Office, Health Quality Council

What we hope to leave you with:

A better understanding of the Saskatchewan health care system’s commitment to and early implementation of Lean methodology

An increased familiarity with some of the most common Lean concepts and methods we are using in Saskatchewan

What is Lean? • Lean is a set of operating philosophies and methods that

help create maximum value for patients by reducing waste including the waste of time waiting for service. It is often referred to as a learning and management system.

• Way of managing and delivering health care, and a new way of relating to and working with patients as partners in their care.

Source: www.betterhealthcare.ca

Why Lean, Why now, Why at such a scale?

A burning platform…• Unsafe health care

– Estimates of one to two avoidable deaths per day in health system (extrapolation from Baker and Norton 2003 study)

• Long waits for services

- over 15,000 waiting more than 3 months for elective surgery in 2010

• Unrelenting expenditure growth in health care costs

– Greater than 7% per annum from mid-1990s to late 2000s

a compelling vision…• “Patient First” must be

embedded as a core value in health care.

• Health care in Saskatchewan needs to function as a cohesive system.

• Frontline providers must be empowered to deliver patient- and family-centred care.

…and disquiet with the status quo.

• Jönköping County (Jönköping, Sweden)

• Southcentral Foundation (Alaska)

• Virginia Mason Medical Center (Seattle, Washington)

• Intermountain Healthcare (Salt Lake City, Utah)

• National Health Service (England)

• Veterans Health Administration (USA)

• Kaiser Permanente (USA)

Learning from high-performing, innovative systems greatly influenced our approach

• Develop and grow leaders for change

• Commit to a consistent, rigorous, disciplined improvement methodology

• Transparent measurement

• Engage and mobilize people

• Align processes, priorities

• Spread (replicate) innovation

Key “take aways” from these systems and their transformation efforts…

2012: a new partnership emerged

Patient First Review: “Keep the Best, Fix the rest”“Fix” = Eliminating waste; waste is anything that does not

add value in the eyes of the patient = LEAN

Reducing walking

Reducing waits

Reducing inventory

Eliminating defects

Our approach to making care safer and better• Set provincial health strategy collectively (Hoshin Kanri or

Strategy Deployment)

• Develop infrastructure to support and coordinate continuous improvement efforts

• Build improvement science capability among our leaders & our entire health care workforce (40,000 strong),

• Connect learning and doing with achieving health system priorities via Improvement Events

• Working in partnership with patients and families

Hoshin Kanri: Key characteristics

• Focus on a few key breakthrough improvements (or hoshins)

• Alignment of the entire organization (and health care system) around these breakthroughs

• Shared input and responsibility for plan and goals

• High participation throughout the organization

• Equal attention to end results and the methods for achieving them

Our approach to making care safer and better• Developing Infrastructure to Support and Coordinate

Efforts (Establishing infrastructure)– Quality departments or units transitioned to Kaizen

Promotion Offices in all RHAs, Cancer Agency, Ministry of Health, 3sHealth, eHealth– Presently over 100 employees in the health system

dedicated to improvement– Creation of Provincial Kaizen Promotion Office (housed

at HQC)– Consistent, standardized approach and use of Lean tools– Aim to have 1-2% of workforce with deepened capability

to lead & do continuous improvement

• Building improvement capability among our leaders and health care workforce (40,000 strong)– Over 600 leaders (CEOs, VP, Directors, physicians

and improvement staff) currently in Lean Leader Certification)• 83 certified to date• Over 40 physicians in training

– Over 16,000 staff have completed Kaizen Basics course (on track to reaching all 40,000 by 2017)

Our approach to making care safer and better

• Learning and applying tools and methods via various improvement events– From January 2012 to March 2011: more than 300

improvement “events” engaging thousands of staff (e.g., 207 Rapid Process Improvement Workshops (RPIWs), 15 3Ps, dozens of 5S events, 28 Kanban teams, 88 Mistake Proofing projects)

– Lean facility design in two of our three major capital projects (MJUH, SCH)

– Lean “design” applied to Primary Health Care sites, staff scheduling and provincial laundry services

– Patients and families participating in improvement events

Our approach to making care safer and better

Lean is about learning to see

A snapshot of our work• Built from direct observation on the Gemba• Identifies the steps in our work• Highlights where things tend to run amuck in the process (Starbursts)

Value Stream Map

The Waste Wheel• Identifies opportunities for improvement• Generated by direct observation and by the staff who do the work

Types of Waste

Making too much

Doing too much

Time on Hand

Stock on Hand

Movement of Things

Movement of People

Broken or defective Products/

Equipment

All of which can be

deemed as unnecessary

distractions in our everyday

work

Understanding Movement and Flow• Built from direct observation – by following patients, families, providers,

medication, supplies, information and equipment.

Spaghetti Diagram

Visual ControlsSignals in our System• How can we make it easy to know what the right thing is every day

Visual Controls

Mistake Proofing DevicesPreventing errors and eliminating defects• Making it difficult to do the wrong thing and even better, making it

impossible to do the wrong thing.

Mistake ProofingUnderstanding our Roles, Responsibilities & Tasks• Having clarity in who does what is helpful to ensure we are all working to

our best ability to provide care for our patients.

Standard Work (SW)

Daily Visual Management BoardsDaily Visual Management (DVM)Understanding our Collective Work• Making information visible• Identifying , talking about and testing ideas to improve your work on a daily basis

Personal Production Board Team Production Board

Unit Level DVM Board Service Line Visibility Wall

Cascading Communication• Making work visible across the multiple levels in our system

Regional Walls

Provincial Walls

Communication Cascades continue• To regional and organizational walls and up to a provincial walls on a quarterly

basis

Lean is about learning to do

RPIWTry-storming change on the Gemba• Senior Leaders, managers, point of care staff from the area , and patients

come together to test and implement improvement ideas over 5 days.

Rapid Process Improvement Workshop (RPIW)

RPIWEliminating Defects in our WorkSenior Leaders and managers working together to identify and redesign mistake-prone situations, to ensure safe care for patients and providers.

Mistake Proofing Project Team

RPIWBuilding, designing or redesigning a better future • 3P stands for Production Preparation Process and is a Lean method• Highly engaging and creative workshop to rethink what’s possible

3P Workshop

Managing Inventory• Built on the concept of just in time and visual cues, to make it easy to find,

fill and reorder materials and supplies.

Kanban Seminar

A well organized work place• Organizing and sustaining the orderliness of your workplace, to allow you to

do your best work everyday.

5S Campaign

Leaders’ Impressions of SK’s Transformation“I wouldn’t want to be anywhere else…because I want to be part of this; I want to see it succeed. At a very personal level, it is the most

satisfying thing I have ever been associated with.”Maura Davies, CEO, Saskatoon Health Region

"The Saskatchewan Union of Nurses welcomes the opportunity for front-line care providers to have their voices heard…A focus on

patient- and family-centred care using best practice evidence and Lean principles will improve the patient experience and return

nursing to a rewarding career."Rosalee Longmoore, Past President , Saskatchewan Union of Nurses

“I’m a lot less frustrated…I can see things happening in my community which is the whole purpose why I ever volunteered to

be in a regional health authority in the first place.”Tina Rasmussen, Board Chair, Keewatin Yatthe Health Region

Staff’s experiences with Lean

“That RPIW really proved what lean was all about; making small incremental improvements…When something doesn’t work, you try a different approach and get expertise from the people at the point of

care and service. I love seeing the shared education that happens when we cross pollinate on rapid process improvement workshop teams.”

Lisa White, Kaizen Promotion Office, Saskatoon Health Region

“Each potential and true injury is treated and addressed as an opportunity for learning and prevention with frequent team

huddles and transferring/lifting/repositioning (TLR) audits…This has been effective and inspired everyone to be more aware. Marie Legault Lalonde, Unit 3-2 Manager, Wascana Rehabilitation Centre

Saskatchewan’s Implementation of Lean

We are cultivating the discipline required to stick to and be successful in attaining our ambitions

Saskatchewan’s Implementation of Lean

Working differently means we are embracing the complexity of Saskatchewan’s health system and the challenges we face.

The commitment to and ambition of the health system to “thinking and acting as one” is unprecedented.

“When it comes to Lean, Saskatchewan hasn’t even hit kindergarten.”

Maura Davies, President & CEO, Saskatoon Health Region

And probably the most important lesson learned so far: Humility

Want to learn more?