Check out this introduction to Lean processes in a health care setting—touching on 5 keys to Lean success. This presentation is from a recent AORN webinar, which is available for replay at http://bit.ly/188O2uQ. Get complete Lean instruction and tools for implementation during a workshop in Denver, CO; more information on these August and September events available at http://bit.ly/14B9gLu.

1. 5 Keys to Lean Success:
Avoiding Common Lean Pitfalls
Tony Gorski BSIE, MBA
Tuesday, June 25th, 2013

2. • Tony Gorski is CEO of Safer Healthcare. Mr. Gorski is an award-
winning speaker, published author and recognized subject matter
expert in helping hospital boards, CEOs and management teams
transform operational performance and creating High Reliability
Organizations (HROs). Mr. Gorski is also driving the launch of
www.MyRounding.com, an iPad Leadership Rounding application
for directors, managers and frontline staff. Mr. Gorski holds a
Bachelor of Science in Engineering from Marquette University and
a Masters of Business Administration from the University of North
Carolina in Chapel Hill. Mr. Gorski currently resides in Denver,
CO.
Tony Gorski, BSIE, MBA

3. Disclosure Information
Speaker:
Tony Gorski, BSIE, MBA
No Conflict
Accreditation Statement
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on
Accreditation.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
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REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.
Planning Committee:
Susan D. Root, MSN, RN, CNOR
Manager Perioperative Education, AORN
No conflict
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship
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7. No conflict of interest

4. Discuss 5 keys to making Lean work
and improving your probability of
success.
Objective

5. Quality is today’s health care mandate. Yet, there is a dark cloud blurring the
vision of many nurse executives today because Lean has had some false
starts and stops in days gone by.
Ask 10 staff members what the definition of Lean is—chances are you will
get 10 different definitions.
Today we work in broken processes that require excellent people to
achieve average results. Many nursing processes are inherently setup to fail.
Lean running hospitals think differently – focused on building excellent
processes. The key is applying Lean in the right way. While 90% of hospitals
are doing Lean, less than 10% are “running” Lean.
The Lean Dilemma

6. In this webinar, we will discuss 5 keys to making Lean work and improving your probability
of success:
1. Focus on throughput – this is one of the most powerful metrics for Lean, and you get
a lot of other things for free, such as patient satisfaction, error rates, etc.
2. Avoid focusing on clinical tasks – Instead, focus on the things that get in the way of
performing clinical tasks.
3. Don’t make every nurse a Lean expert – not every member of your staff needs to be
a Lean expert.
4. Leading 3-steps ahead – Lean work must be facilitated by someone can think three
steps ahead at all times to guide the transformation.
5. Educate yourself and then educate your team members – we must be able to think
both from a process perspective and a clinical perspective.
5 Keys to Driving Success

7. Six Aims for Improvement
“Health care should be:
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable
These aims are not new….Yet American
health care fails far too often with respect
to these aims, despite enormous cost and
dedication and good efforts of millions of
American healthcare workers”

8. Six Aims for Improvement
The IOM “Chasm” Report
gives us a vision of where
to go
Lean Thinking gives us a path to
get there
– Process Improvement
Framework
– Tools and Problem-Solving Skills

9. Lean Calibration
• What is it?
– The word “Lean” – only 1 word, but 100 definitions
– Toyota Production System – not a Panacea
– Bunch of tools or a fundamental shift in mindset
– Cost-focused (common interpretations):
• Reduce waste, Operational efficiency, Cost reduction
• Customer-focused…….or Patient-focused
– Speed and safe response to customer demand

10. Random Acts of Lean
 Value-Stream Mapping
 Workplace Organization (5S), (6S), (7S)
 Six Sigma
 Visual Management
 Total Preventive Maintenance
 Balanced Scorecard / Lean Scorecard
 Kaizen Events
 Theory of Constraints
 Workouts
 Kanban
 Reduce Waste – 7 Wastes, 8 Wastes, etc
 Improve Efficiency
 Hejunka Scheduling
 Standard Work
 Rapid Improvement Events
 Operational Method Sheets
 Changeover Optimization (SMED)
 Case Sequencing
 DMAIC
 Production Preparation Process (3P)
 Process Balancing Tools
 Electronic Kanban Methods
 Benchmarking Practices
 Health Care Execution Systems
 Green Belts, Black Belts
 Mixed-Model Designs
 Drum/Buffer/Rope
 RFID/Bar Code Strategies
 Flow Rate Management
 Cellular Concepts
 Rationalization Practices
 Demand-Driven Metrics
 Flexibility Practices
 Process Mapping
 Velocity Analysis
 Mistake-Proofing (Poka-Yoke)
Common problem…
– Pockets of improvement are not tied or affect bottom line
– Primarily focused on micro areas with micro results
Common answer…
– Many organizations end up creating their own Excellence System or
Operating System

11. Excerpt from U.S. News and World Report…
“…During the visit, a team led by Virginia Mason's chief of medicine met with a Toyota guru, a
sensei who absorbed the Toyota approach into his very marrow. Examining a layout of the
hospital, the sensei learned that there were waiting rooms scattered across the campus.
"Who waits there?" the sensei had asked.
"Patients," said the chief of medicine.
"What are they waiting for?"
"The doctor."
The sensei was told there might be a hundred or so such waiting rooms and that patients wait
about 45 minutes on average.
"You have a hundred waiting areas where patients wait an average of 45 minutes for a
doctor?" He paused and let the question hang in the air.
"Aren't you ashamed?“
What Medicine Can Learn From Business
(U.S. News & World Report, June 17, 2008)

12. Push Facility
Originally Built to Push/Batch Product
Traditional Push & Power of Pull

13. vs.
Push Facility Pull Facility
Originally Built to Push/Batch Product
Originally Built to Pull to Customer Demand
vs.
Traditional Push & Power of Pull

14. • Consider the process of patient care
– from a cross-functional viewpoint instead of individual
functional departments
– Get past the trees to see the forest
• Both outcomes and patient satisfaction
– depend on a healthcare experience that is a smoothly
flowing series of connected steps
• HCAHPS and Jiffy Lube…
Outcomes vs Patient Satisfaction

15. Where to focus efforts?
• The 90/10 Rule of Value
– Often, the same amount of effort applied to
the non-value added activity (the 90%) as
the value-added activity (the 10%) yields
significantly greater results
– However, most improvements focus
solely on the 10%
• In health care, this applies to both paper
process(ing) and patient process(ing)
10%90%
Time
Non-value added activity Value added activity
Typical NVA Activities:
 Counting
 Handling
 Waiting
 Stocking/Storing
 Signoffs
 Multiple Order
Entry/Processing
 Moving

16. Where to focus efforts?
Value Added Non-Value Added
1. Defects
2. Overproduction
3. Waiting
4. Transportation
5. Inventory
6. Motion
7. Excess
Processing
Typically 90+% of all cycle
time is non-value added

17. Throughput - Definition
The time it takes to flow all the way through a process or value
stream, from start to finish including waiting time, process
time, queue and non-value added time.
• What are your significant value streams?
• What are throughput times?
• Are they measured in seconds, minutes, days, weeks, etc.?
• Use Value Stream Mapping to help identify a future state
with improved Throughput

18. TimeStart Finish
Waiting WaitMove Wait Move/Wait = Value Added Time
(VA)
= Non-Value Added
Time
(NVA)
Tests TreatTriage
Traditional Focus  Improve the VA processes
Lean focus  Eliminate the NVA processes
Separating Waste from Value

19. It’s Affect on 7 Wastes
• The seven types of waste
– Over-production
– Waiting
– Transportation
– Over-processing
– Inventory
– Motion
– Defects
Throughput

20. Throughput - Examples
• Admission to discharge
• Invoice process
• Filling medications
• Length of stay
• Lead times on purchased items
• Room turnovers
• Time to fill employee requisition
• IT help desk – problem resolution process

21. • Reduce waiting time
• Reduce non-value added activities
(orange vs blue)
• Reduce total amount of work-in-process
• Accelerate value added processes
• Improve linkages between processes
• Implement “pull” techniques
• Focus on flexibility
Throughput – How to Improve

22. Chase Variation, not Averages
• Variability recognizes that processes do not produce
identical results every time (inherent in nature)
– Variability may be caused by identifiable forces acting on the process or by
minute fluctuations in the process itself
– Range (low to high spread), standard deviation (relative dispersion from the
mean), and variance (how far a set of numbers is spread out) are common
measures of variability
μ = average
σ = variation
The Normal
Distribution Curve

23. Leading 3-steps Ahead
• Presents a clear path moving forward
• Must have a clear sense of where they are currently, as
well as the ideal state to which they are heading
• A leader is a change agent, not a magician
– The leader doesn’t assume all tasks/actions
• Lean leaders create a ‘creative tension’ for progress
“Too many times, Lean Leaders are ‘forced’ into the roles and are setup
to fail. Lean work must be facilitated by someone can think three steps
ahead at all times to guide the transformation.”
“Rely on someone who has ‘been there, done that’ versus struggling alone.”

24. Shared
Vision
Skills /
Training
Incentives Resources
Action
Required
Successful
Change
Skills /
Training
Incentives Resources
Action
Required
Confusion
Shared
Vision
Incentives Resources
Action
Required
Anxiety
Shared
Vision
Skills /
Training
Resources
Action
Required
Gradual
Change
Shared
Vision
Skills /
Training
Incentives
Action
Required
Frustration
Shared
Vision
Skills /
Training
Incentives Resources
False
Starts
Leaders Identify the Missing Link

25. Nurses and Lean Experts
not every member of your staff needs to be a Lean expert...
but every Lean tool should be very well known by at least one person
on your staff…
“I just don’t process things that way”
“It’s too much and can all be so intimidating”
“I spend more time trying to understand the proper use of
Lean language than I do getting anything done”
“One person is the Value Stream Mapping leader, another is the Standard
Work leader, another the workplace organization leader”
“I’m very comfortable with identifying Standard Work, but the rest frankly
confuses me”
“Now I can focus on being great on one thing versus a laggard at everything”

26. Educate Not Just on Tools…
• Educate yourself
– to ensure you can identify the roadblocks and know how to
address them
• Then educate your team members – properly
– not a one-size fits all mentality
“we must be able to think both from a
process perspective and a clinical
perspective”

27. In this webinar, we will discuss 5 keys to making Lean work and improving your probability
of success:
1. Focus on throughput – this is one of the most powerful metrics for Lean, and you get
a lot of other things for free, such as patient satisfaction, error rates, etc.
2. Avoid focusing on clinical tasks – Instead, focus on the things that get in the way of
performing clinical tasks.
3. Don’t make every nurse a Lean expert – not every member of your staff needs to be
a Lean expert.
4. Leading 3-steps ahead – Lean work must be facilitated by someone can think three
steps ahead at all times to guide the transformation.
5. Educate yourself and then educate your team members – we must be able to think
both from a process perspective and a clinical perspective.
5 Keys to Driving Success

28. Your Takeaways…
• Feel
– What do patient waiting times trigger in me?
– Have I felt the “Missing Links” managing change?
• Think
– Are we more like McDonald’s years ago or like Subway today?
– Are we doing “Random Acts of Lean”?
– Am I focused on the ”ORANGE” or the “BLUE”?
– Are we chasing Averages or reducing Variation?
• Do
– Eliminate something ”ORANGE”

29. This highly-concentrated three day, hands-on workshop teaches
critical thinking, problem solving, and leadership skills that are
fundamental to creating and sustaining actual change using LEAN
strategies. Work teams highly recommended as this course “explains
by doing.”
August 20-22
September 18-20
Denver, CO – AORN Headquarters
www.aorn.org/LeanLeadership
Know what counts. Measure what matters. Deliver results.