Lean Hospital Management

20th November 2009

 The World We Live In
Highly Competitive
Dynamic – Fluid – Ever Changing
Companies Require -
– responsiveness
– flexibility
– profitability/consistent cash flow

Lean Manufacturing
What the organization wants
What that leads to:
• Available and prompt care
• Smooth operations • Better patient outcomes
• Ensure patient safety • Increased patient satisfaction
• Improved financial viability
• Provide quality care • Improved patient throughput
• Effective patient treatment • Improved publicly reported
• Utilized staff and resources information
• Higher employee involvement
and satisfaction
• Reduced LOS
 What do our Patients need?
• Favorable patient outcomes
• Patient safety
• Implement new procedures and capabilities
• Slow rising healthcare costs
Virginia Mason Medical Center continued

• Using lean concepts, Virginia Mason

completely redesigned the process for
chemotherapy patients so that everything
flows to the patient as opposed to the patient
flowing through the process.
• Lean initiatives have resulted in:
– Savings of $6 million in capital spending,
– Freed up 13,000 square feet,
– Reduced inventory costs by $360,000, and
– Reduced the distance hospital staff walk each day
by 34 miles.
Chapter 11: Just-in-Time Systems 5
 Valley Baptist Hospital in Harlingen, Texas
continued

• One specific goal of this project was to reduce the

time from when a patient discharge order was entered
into the computer until the time the patient was
transported from the room to 45 minutes.
• Process improvement team began by mapping the
current patient discharge process.
• The process improvement team developed a new
standard operating procedure consisting of six steps
for the patient discharge process.
• Mean time to discharge a patient was reduced by
74% from 185 minutes to 48 minutes.

Chapter 11: Just-in-Time Systems 6

Applications of Lean in Healthcare
• Laboratories
– Reducing Turn Around Times and Errors
• Emergency Departments
– Reducing diversions, improving flow
• Outpatient Cancer Treatment
– Reducing patient delays, increasing capacity
• Operating Rooms
– Reducing changeover times, increasing utilization
• Pharmacies
– Reducing errors, improving response
• Food Service
– Reducing wasted food, improving quality
 Why LEAN Works in Healthcare
• LEAN is not a list of tools that applies only to
factories
• LEAN is a philosophy of management that applies
to any system
• LEAN rallies people around goals we can all agree
on:
– Patients and Employees
 What is Lean?

• Originated within Toyota in 1950’s

• Its use focuses on elimination of Waste
• Enhancing ‘Value-Added’ operations
• A method to reduce complexity and
improve process flow
Lean adalah cara yang sistematis untuk mendesain dan
meningkatkan proses atau value stream untuk:

• Menghilangkan pemborosan
• Meningkatkan kualitas
• Menekan biaya
• Memuaskan pelanggan/pasien
• Meningkatkan kepuasan karyawan
• Meningkatkan keselamatan kerja
Lean Health care

• Most cost efficient care

• Eliminating waste

• Work sampling

• Reducing excessive inventories

 LESS MEANS …….
(Lebih sedikit artinya ……….)

• Less time (lebih sedikit waktu)

• Less space (lebih sedikit area kerja)
• Less human effort (lebih sedikit upaya)
• Less equipment (lebih sedikit mesin)
• Less materials (lebih sedikit material)
WHAT IS LEAN THINKING?

“The endless transformation of

waste into value from the
customer’s perspective”.
(transformasi terus-menerus dari pemborosan
menjadi sesuatu yang bermanfaat bagi pelanggan)
“Womack and Jones”
 “Lean” means doing without
what’s not needed.
It’s taking out the unnecessary stuff in
processes, so that everything becomes
more efficient.

(“Lean” berarti melakukan tanpa hal yang tidak

diperlukan. Ini akan mengeluarkan semua hal yang
tidak perlu dari proses, sehingga segalanya menjadi
lebih efisien).

Mike Rona
President Virginia Mason Hospoital
TRADITIONAL VERSUS LEAN

Traditional
Pemotongan biaya (cost cutting)

Lean
Keluarkan pemborosan dari
proses kerja
TRADITIONAL VERSUS LEAN
Traditional

waste Cash collected

Customer order

time

Lean
Customer order Cash collected

Waste

Time (shorter)
 7 WAYS OF LEAN IN HEALTHCARE
1. REDUCE NEVER EVENTS
2. SUPLLY CHAIN IMPROVEMENTS
3. DELAY OR CANCEL CONSTRUCTION AND
EXPANSION
4. REDUCE OVERTIME
5. REDUCE LENGTH OF STAY
6. REDUCE UNNECESARRY TESING AND DIAGNOSTIC
7. REDUCE DELAYS AND ERRORS IN BILLING
Kaizen Philosophy
• Employee-led continuous improvement
• Five steps
• Specify value
• Map and improve the value stream
• Flow
• Pull
• Perfection
• Even if it isn’t broken, it can be improved.

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LANGKAH-LANGKAH ANALISIS
LEAN
1. TETAPKAN VALUE STREAM
2. GAMBARKAN VALUE STREAM MAPPING  CURRENT FLOW
3. IDENTIFIKASI WASTE YANG ADA PADA VALUE STREAM TSB DENGAN
MELAKUKAN KAJIAN PADA VALUE STREAM MAPPING
4. LAKUKAN ANALISIS APA YANG MENJADI PENYEBAB TERJADINYA
WASTE
5. RENCANAKAN SOLUSI PERBAIKAN AGAR WASTE DAPAT
DIMINIMALISIR ATAU BAHKAN DIHILANGKAN – PILIH TOOL YG COCOK
6. BUAT FLOW CHART SETELAH DILAKUKAN PERBAIKAN
7. IMPLEMENTASIKAN
VALUE STREAM MAPPING
PENGGUNAAN

Value Stream Tentukan Value Stream mana

Scope yang perlu ditingkatkan

Current state Pahami bagaimana operasi saat

drawing ini. Sebagai “Baseline””

Future state
Rancang alur yang lean dengan menggunakan
drawing
prinsip Lean. Sebagai Visi Kedepan.

implementation
plan Kembangkan rencana implementasi yang rinci
agar sasaran dapat tercapai

Implementation Sasaran Value Stream Mapping

1. TETAPKAN VALUE STREAM
APA ITU VALUE STREAM?

Adalah semua aktivitas,

baik yang memberi nilai
tambah maupun tidak, yang
dibutuhkan untuk menyelesaikan
satu produk/pelayanan atau famili
produk/pelayanan dari awal hingga akhir
 VALUE STREAM MAPPING
• Suatu metoda untuk melihat proses penyediaan
pelayanan/barang
• Sekaligus memetakan alur produksi dan alur informasi
• Memvisualisasikan alur proses dari sudut pandang sistem
Value Stream Mapping
• Process map of the value stream
• Includes information processing and transformational processing
• Value-added steps: “Would the customer be willing to pay for this
activity?”
• Non-value-added steps
• Necessary
• Unnecessary

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 MANFAAT VALUE STREAM MAPPING

• Memvisualisasikan seluruh proses operasi secara terintegrasi dan

tidak sekedar masing-masing proses saja. Anda dapat melihat
alirannya.
• Membantu melihat lebih dari sekedar pemborosan, tetapi juga
penyebab pemborosan dalam value stream.
• Mengaitkan alur material dan alur informasi daalam satu
keterkaitan.
• Menyamakan persepsi tentang kondisi saat ini.
• Memperjelas perlunya keputusan untuk membuat produksi
mengalir.
• Berperan sebagai cetak biru dari implementasi.
• Meningkatkan kemampuan untuk melihat jauh ke depan.
• Menyatukan konsep Lean dan tehnik-tehniknya ke dalam value
stream.
2, GAMBARKAN VALUE STREAM
 Diagram created
with eVSM
software from
GumshoeKI, Inc., a

Value Stream Mapping

Microsoft Visio
add-on.

Nurses’ time spent on Rooms Long wait after

non-patient care not available cleared to discharge
House- Anesthes- Social
Supplies Radiology Lab Pharmacy
keeping iology Services

LOS Slow Education

turnaround late
Rooms
Stabilize
unavailable
Porter
Incorrect
patient forms
Labor
Post
Patients Admitting Triage and Discharge
Partum
Delivery
0-2 hr 1-3 hr 1-8 hr 1-5 hr
30-90 min 1-3 hr 1-60 hr 20-80 hr 3 hr
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reserved.
Value Stream Mapping is...
 Value Stream – Anatomic
Pathology
Patient & MD I

Transcriptionist I
Pathologist

Specimen I
Collection
Send to
Grossing
I
Embed Slide
I Grossing Processing
& Cut
Staining
Making

I I I I
 Laboratory Layouts Drive Waste

Layout is driven by
departments

Benches interfere with

straight-line walking,
encourage batches
Clinical Laboratory Product Flow
Outpatient Oncology Patient “Flow”
Value Added
• Blood drawn
• MD consult
A • Needle into Port

NVA But Required

• Check In / Check Out
B • Moving from room to room

ARRIVAL TO LATENESS FOR

NVA, “Pure Waste”
TREATMENT TREATMENT • Waiting for Check In
PATIENT (HOURS) (HOURS) • Waiting for MD
A 2.5 0.42 • Waiting for Treatment
B 3.5 1.08
AVG 3.0 0.75
Re-Work Loops Cause Delays
3. IDENTIFIKASI WASTE
 WASTE ~ PEMBOROSAN
PEMBOROSAN =
Elemen kegiatan Value Added: 5%
operasi yang tidak
memberi nilai
tambah, tetapi
Non – Value Added: 95%
menambah waktu,
upaya dan biaya
WASTE ~ PEMBOROSAN

Pemborosan dilihat dari

kacamata pasien/pelanggan
Segala sesuatu yang tidak memberi nilai tambah
pada produk/jasa akhir

Semua aktivitas yang tidak mau dibayar oleh

pelanggan (pasien), seandainya mereka tahu
bahwa hal tersebut terjadi
Taiichi Ohno's Seven Wastes
Processing Motion
•Unnecessary movement
Unnecessary processes
or movement that does not
and operations
add value.
traditionally accepted as
•Movement that is done
necessary
too quickly or slowly.

Time Defects
•Waste related to costs
•Waiting for people or
for inspection of
services to be
•Defects in materials

Waste
provided.
•Time when your and processes.
•Customer complaints.
processes, people and
•Repairs
machines are idle.

Overprod Transport
uction Inventor ation
Conveying, transferring,
Producing what is
unnecessary, when it is y picking up.setting down,
piling up and otherwise
unnecessary, and in •Maintaining
unnecessary amounts moving unnecessary
excessive amounts
items.
of parts, materials, or
information for any
length of time.
•Having more on
 8 TYPES OF WASTE IN HEALTH CARE
OVERPRODUCTION
Waste overproduction di dalam proses pelayanan rawat jalan dan rawat inap yang
melitputi mengeluarkan hasil tes laboratorium berulang-ulang dengan informasi yang
sama.
WAITING
patients/staff standing idle, patient in waiting room, wait for lab results, delay in
obtaining appointment, patients waiting for discharge, physicians waiting for test
results
TRANSPORTATION
Unnecessary transportation dalam pelayanan rawat jalan dan rawat inap meliputi,
perpindahan pasien yang berlebih dan mengambil berkas yang letaknya jauh yakni
pengiriman berkas rekam medis ke tempat periksa.
EXTRA PROCESSING
Overprocessing pada instalasi rawat jalan dan instalasi rawat inap yakni pencatatan
identitas pasien dilakukan berulang-ulang, yakni pada dokumen rekam medis, buku
register, kartu kendali, dan komputer.
 8 TYPES OF WASTE IN HEALTH CARE
INVENTORY
Unnecessary Inventory yang terjadi adalah persediaan obat yang berlebih,
persediaan peralatan laboraturium yang berlebih, dokumen yang masih diproses
yakni penumpukan dokumen pasien, dan persediaan peralatan rumahsakit yang
berlebih yakni kartu rekam medis yang belum terpakai.
MOTION
Unnecessary motion yang terjadi yakni mencari dokumen rekam medis,
mengumpulkan peralatan medis, adanya gerakan yang tidak diperlukan pada bagian
informasi dan pendaftaran untuk menjangkau barang-barang seperti mencari kuitansi
alat tulis atau mencari obat.
CORRECTION
Defect terjadi baik di rawat inap maupun instalasi gawat darurat yakni seperti salah
memberi obat, dokter mengganti resep yang telah dibuat pada pasien karena obat
pada resep sebelumnya tidak ada dalam farmasi, ketidak kelengkapan kebutuhan
pasien untuk administrasi, dan pasien dibawa ke ruang pemeriksaan yang salah.
• UNDERUTILIZED PEOPLE
Waste underutilized abilities of people yakni dokter kurang memberikan edukasi
pada pasien, perawat di Instalasi Gawat Darurat kurang memberikan perhatian yang
optimum kepada pasien..
 IDENTIFIKASI WASTE
No. Jenis Waste Kondisinya bagaimana Bermasalah tidak
1. Inventory
2. Motion
3. Correction
4. Over Production
5. Waiting
6. Transportation
7. Extra Processing
8. Under Utilized People
 Tools
• Takt time • Standardized work
• Throughput time • Kanban
• Five Ss • Single minute
• Spaghetti diagram exchange of die
• Kaizen blitz or event (SMED)
• • Flow
Jidoka
• • Pull
Andon
• Heijunka
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 4. ANALISIS PENYEBAB
• FISHBONE DIAGRAM (ISHIKAWA ANALYSIS)

• ROOT CAUSE ANALYSIS (RCA)

5. PERBAIKAN SOLUSI
Takt Time
• The speed with which customers
must be served to satisfy demand for the service.
Available work time/day
Takt time 
Customer demand/day
• Cycle time is the time to accomplish a task in the system.
• System cycle time is equal to the longest task cycle time in the system
—the rate at which customers or products exit the system, or
“drip time.”

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Throughput Time
• Time for an item to complete the entire process, which includes:
• Waiting time
• Transport time
• Actual processing time

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Riverview Clinic
Cycle, Throughput, and Takt Time
Patient check-in Move to examining room
3 minutes 2 minutes

Wait 15
minutes

Nurse does Physician exam

preliminary exam and consultation Visit complete
5 minutes 20 minutes
Wait 15 Wait 10
minutes minutes
Diagram created with eVSM software from
GumshoeKI, Inc., a Microsoft Visio add-on.
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Riverview Clinic
Cycle, Throughput, and Takt Time
• Patient check-in cycle time = 3 minutes.
• System cycle time = cycle time for longest task = physician exam and
consultation = 20 minutes.
• Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 = 70 minutes.
•
Takt time  8 physicians  5 hours/day
100 patients/day
 0.4 physician hours/patient
 24 physician minutes/patient.

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Riverview Clinic
Value-Added Time
• Valued-added tasks:
• Nurse preliminary exam
• Physician exam and consultation
• Non-value-added steps, necessary:
• Patient check-in
• Value-added time = 5 minutes (nurse preliminary exam) + 20 minutes
(physician exam and consultation) = 25 minutes.
• Percentage value-added time = 25 minutes/70 minutes = 35 percent.

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Five Ss
• Seiri (Sort)—Separate necessary from unnecessary
items, including tools, parts, materials, and
paperwork, and remove the unnecessary items.
• Seiton (Straighten)—Arrange the necessary items
neatly, providing visual cues to where items should
be placed.
• Seiso (Sweep)—Clean the work area.
• Seiketsu (Standardize)—Standardize the first three
Ss so that cleanliness is maintained.
• Shitsuke (Sustain)—Ensure that the first four Ss
continue to be performed on a regular basis.

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 5S in Healthcare
5S is a workplace organizational tool that creates an environment that allows work
to flow, in safe, organized, intuitive and sustainable way.

Sort : Separate what is

unnecessary

Shine : Clean it up

Set In Order : Organize

Standardize : Establish standard

operating procedures

Sustain : Develop long-lasting

habits
Spaghetti Diagram

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Kaizen Blitz or Event
• Determine and define the objectives Act Plan

• Determine the current state of the process

• Determine the requirements of the process Check Do
• Create a plan for implementation
• Implement the improvements
• Check the effectiveness of the improvements
• Document and standardize the improved process
• Continue the cycle

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Standardized Work
• Written documentation of the way in which each step in a process
should be performed
• Not a rigid system of compliance, but a means of communicating and
codifying current best practices
• Massachusetts General Hospital care paths

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Jidoka and Andon
• Jidoka is the ability to stop the process in the
event of a problem.
• Prevents defects from passing from one step in
the system to the next
• Enables swift detection and correction of errors

• Andon is a visual or audible

signaling device used to indicate
there is a problem in the process.

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Kanban
Empty Empty
Kanban Kanban

Full Full
Kanban Kanban

Task 1 Task 2
Customer
Workstation Workstation
Order
1 2

Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
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Kanban
Signal Signal

patients echo patients CT

Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
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Single Minute Exchange of Die (SMED)
• Used to reduce changeover or setup time, which is the time needed
between the completion of one procedure and
the start of the next procedure
• Steps
• Separate internal activities from external activities
• Convert internal setup activities to external activities
• Streamline all setup activities

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Flow and Pull
• Continuous or single piece flow—move items (jobs, patients,
products) through the steps of the process one at a time without
interuptions or waiting.
• Pull or just-in-time (JIT)—products or services are not produced until
the downstream customer demands them.
• Heijunka—“make flat and level”; eliminate variation in volume and
variety of “production”
• Level patient demand

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Advanced Access
• Patients are unable to obtain timely primary care appointments.
• Advanced access scheduling reduces the time between scheduling an
appointment for care and the actual appointment.
• The goal is swift, even patient flow through the system.

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Advanced Access
Advantages
• Decreases no-show rates
• Improves patient satisfaction
• Improves staff satisfaction
• Increases revenue
• Higher patient volumes
• Increased staff and clinician productivity
• Promotes greater continuity of care
• Increased quality of care
• More positive outcomes for patients

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Advanced Access
Implementation
• Advanced access challenges established practices and beliefs.
• Balance supply and demand:
• Obtain accurate estimates of supply and demand.
• Reduce or eliminate backlog.
• Minimize the variety of appointment types.
• May need to:
• Adjust demand profiles.
• Increase availability of bottleneck resources.

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PLANNING AND IMPLEMENTING VALUE STREAM
IMPROVEMENT
• Kaitkan dengan sasaran perusahaan
• Susun Rencana Implementasi: Apa dan Kapan
• Tetapkan frekuensi review dengan tepat
• Laksanakan Reviews dengan mengikuti aliran di value
stream di lapangan
VALUE STREAM IMPROVEMENT
• Untuk meningkatkan kinerja dari Value Stream,
rencanakan pada “tingkat sistem” dan
laksanaakan pada “tingkat proses”
• Pastikan ketersediaan sumberdaya yang
dibutuhkan untuk mengimplementasikan
peningkatan dalam future-state Value Stream
• Peningkatan proses harus distandarisasi dan
didokumentasikan
• Beri umpan balik pada semua pihak terkait agar
dapat berkontribusi terhadap peningkatan
berkesinambungan
“Lean” on work and workers…

Creative

Concerned
“Lean” on work and workers…

Knowledgeable

A Partner
 TERIMA KASIH

20th November 2009