6-s checklist # of y's: 25 = % date · sort (get rid of what's not needed): - unnecessary...

Sort (get rid of what's not needed):

- unnecessary items have been removed from the area (furniture, storage, things on walls…) Y N

- any incomplete work has been completed or removed to be resolved separately Y N

- a red tag area is used to hold items requiring decisions (no item more than 7 days old) Y N

- work surfaces, drawers and storage areas do not have items in or on them that don't belong Y N

Set in order to flow (straighten):

- all work surfaces, storage areas and equipment are clearly marked and well organized Y N

- locations and containers for items and supplies are clearly marked Y N

- incomplete work or items requiring special attention are separated and clearly marked Y N

- standard information boards have been established (for measurement and management info.) Y N

Shine (clean and solve):

- floors, work surfaces, equipment and storage areas are clean (including the corners!) Y N

- garbage and recyclables are collected and disposed of correctly Y N

- work environment is good (air quality, temperature, humidity, lighting, dust, fumes, floors...) Y N

- when the clean-up activies expose a problem, it is promptly solved and corrective action taken Y N

Safety (make it safe):

- required safety information is posted (Material Safety Data Sheets, Lockout-Tagout, Exits...) Y N

- fire extinguishers, exits and other emergency equipment are clearly marked and functional Y N

-basic job skills training has been done (safety and quality pointers are posted and understood) Y N

-unsafe conditions are promptly resolved (including any place where injury could occur...) Y N

Standardize (tasks):

- roles are identified for keeping the area clean and orderly Y N

-standard tasks related to cleaning and organizing are defined Y N

- it is obvious through visual management tools whether tasks have been done Y N

- this standardization is accomplished without any paperwork Y N

Sustain (keep it up):

- posted Standard Work is being followed Y N

- standard cleaning and work procedures are being followed Y N

- documents and instructions are current Y N

- standard information boards are being used and have current, relevant information Y N

- work area is clean, neat and orderly with no serious unsafe conditions observed Y N

Date:# of Y's: / 25 = %

6-S Checklist

9/13/2013 6S Audit Tool for printing

6S/Standard Work Exercise

J KochA Dordal

• This sheet represents our current work place.• Our job during a 20 second shift, is to strike out the numbers 1 to 49

in correct sequence. Example: 1 2 3• The team score will be represented by the lowest individual score

achieved.• Give the sheets out face down and have someone keep time.• Ask each person to call out their individual scores and mark them on a

flipchart. Circle the lowest and therefore team score.• Ask if they are happy with the score

2From: http://www.lean.org/FuseTalk/Forum/Attachments/5S%20GAME.PPTPacket

1013

23

2730

47

51

58

62

79

40

3Packet

• For our first action, we are going to implement 5S in this area.• The first step of this is “Sort” and so we have removed from the area all

the numbers from 50 to 90 which are not needed.• Same rule apply. Strike out numbers 1 to 49 in sequence during a 20

second shift.

4Packet

1013

23

2730

4740

5Packet

• Having achieved some improvement, we now need to move onto the next step ”Set In Order”.

• We have installed some racking, and we have organized the items so that with Number 1 in the bottom left hand corner, the numbers are located from left to right and bottom to top - examples 1 in the bottom left, 2 in the middle, and 3 in the top left.

• Same rules apply 20 second shift, lowest individual score equals team score etc…

6Packet

1013

23

2730

4740

7Packet

• Having now made a significant step forward, and having ignored “Shine” for this exercise, we must “Standardize”.

• Since we are dealing with numbers 1 to 49 in sequence, it seems logical to re-organize them in a standard way that makes the completion of the work task as easy as possible.

• This should ensure that everyone is able to complete the task (and therefore produce a team score of 49.)

8Packet

Numbers from 1 to 49

10

13

23 27 30

47

40

9Packet

• To show respect for Standards it is necessary to make the “management” of the area visual.

• Returning to our original work area, we have for this assignment two numbers missing. We cannot complete the task without these numbers - so first we have to find them.

• Start a clock running and every 20 seconds, tell them how many “shifts” they have been down looking for the appropriate numbers.

10Packet

1013

23

2730

47

51

58

62

79

40

11Packet

• Now how much easier is it to find the quality problems?

12Packet

Numbers from 1 to 49

10

13

23 27 30

47

40

13Packet

8 Wastes – Walk Form

Unused Human Potential:

Waiting:

Inventory:

Transportation

Defects:

Motion:

Overproduction:

Processing:

Packet 1

Visibility Wall Checklist

Is the Network format wall in place?

Is it color coded with clear goals?

Is the trend data current?

Are A3s posted and up to date?

Did the A3 work improve the metrics?

Packet1

Daily Metric Board Checklist

Is the Daily Metric board in place and the format correct?

Is the trend data current with a goal?

Can you tell status of a metric and reasons for any misses?

Are action plans posted and up to date?

Have actions improved the metrics?

Packet2

III. GOALS/TARGETS What specific outcomes (in measurable or identifiable terms) are required?

IV. ANALYSIS What is the root cause(s) of the problem?

- Choose the simplest problem solving-analysis tool (5-Whys, Fishbone Diagram, Process Analysis Tree, etc.) that clearly shows the cause-and-effect relationship.

VII. FOLLOW-UP What issues can be anticipated? - Ensure ongoing PDCA. - Capture & share learning.

TITLE: What are you talking about? OWNER/DATE:

I. BACKGROUND V. PROPOSED COUNTERMEASURES Why are you talking about it?

What is the business problem you are trying to solve?

What is your proposal to reach the future state, the target condition?

How will your recommended countermeasures affect the root cause to achieve the target?

II. CURRENT CONDITIONS Where do things stand today? - Show visually using charts, graphs, drawings, maps, etc. to make the problem clear.

What is the Problem?

VI. PLAN What activities will be required for implementation and who will be responsible for what and when?

What are the indicators of performance or progress?

- Incorporate a Gantt chart or similar diagram that shows actions/outcomes, timeline, & responsibilities. May include details on specific means of implementation5 why

Standard workProcess mapping

6SStandard Work

PDCA

Daily metrics

3Packet

Huddle Checklist

Start on time

Have each process owner review their metric

How does that metric impact the patient/ team

Review process for problems

Record issues

Create plan as appropriate

Packet 4

Future State Questions

1. What work areas need better organization?

(Use 6S tool)

2. What work areas need better daily metrics so the status is more obvious?

(Use Visual Management/ Daily Management System tools)

3. What work area has too much variation?

Where is the process not consistently done the same way by all staff?

Where is the quality defect rate too high?

Where are cycle times too long?

(Use Standard Work & A3 problem solving tools)

4. Where is there too much time spent changing from one process to another

(Use Turn Over time/Set-up time reduction tool)

5. Where are there material stock-outs?

Where is there too much inventory?

(Use Material Pull tool)

1

STANDARD WORK FOR: Leadership Gemba Visit – Perioperative Services Who: DDiirreeccttoorr/Administrator When:

STANDARD PROCESS STEP DESCRIPTION NOTES TIME

Planning the visit: Why am I visiting the GEMBA today and which locations will I be visiting?

#1 - Identify “basic” tools that are needed to effectively deliver patient care, and director plans to meet current needs. #2 - Assess opportunities to improve environment and aesthetic appearance (first impression) for customers of perioperative services. #3 - Review plans for utilization of space to streamline patient flow and create capacity in other areas.

FY ’13 Goal review and 6-month plan

#1- Review director’s initial assessment of goals, metrics and team engagement with administrator #2- Identify “next steps” for team- what data/communications/process changes are required to achieve FY’13 goals. What are potential barriers? #3- Report plans for perioperative value stream map to administrator

Determine need for additional leader involvement (Support)

Administrator, Anesthesia leadership, Medical Director

Set Schedule and map a deliberate route

Specific major projects

Review action/completion plans from previous visits

Establish goals for your planned visit Overarching Goal: Short term: Identify systems/processes that are required to ensure a safe, efficient and customer-friendly surgical experience for our patients. Ensure that director plans are aligned with administrator expectations. Long term: Discuss strategic plans for perioperative services- i.e. increasing volume, service lines

Write questions to ask based on needs and goals for this visit and previous visits.

Go to the Gemba

STANDARD WORK FOR: Leadership Gemba Visit – Perioperative Services

Sample Questions for SPD/OR Gemba Visit (Ask the people who do the work) Tell me about what you're

working on today What makes your job fun? Hard?

What would make it easier? Tell me why you think it's

important. Have you encountered any

problems as you work through this task (process)?

Tell me what has been done (or what you have done) to date to resolve any problems. Does it work when followed?

Ensure metrics are up-to-date Record issues and create a plan to resolve problems

Recognize top performers (written thank you)

Revisit regularly

9/23/2013

1

Driving Culture Change A Lean Daily Management System

Jodi Koch Director, PeriOp Services

Andrew Dordal Sr. Lean Coach

1

Class Description: Driving Culture Change: A Lean Daily Management System

▪ Lean management tools are used to identify and remove waste from processes with the intent of improving flow through a system. Daily management is a disciplined process that can drive culture, align goals, improve results, and increase staff engagement.

▪ The speakers will share how they have embraced Lean strategies in perioperative services in their Magnet hospital, achieving a 75% reduction in operating room hold times, gaining and sustaining an on-time first-case start rate of greater than 85%, and achieving a five-minute reduction in turnover time.

▪ The speakers, who have worked together as a successful team, will take you down their path of culture change using Lean tools, daily management metrics, visibility walls, and problem solving. You’ll participate in practice exercises and receive tools that you can implement in improving daily operations in your own facility.

2

Roadmap for Learning

▪ Introductions

▪ What is Lean? – VA/NVA 8 Wastes

– 6S, Standard Work

Break

▪ VSM Lunch

▪ Lean Daily Management – Daily Metrics

– A3 Thinking

Break

▪ Culture Change

This identifies areas where you can take a learning and apply at your location!

Go do!

3

Who are you? Job responsibility Geographic

Admin/Sr Leader Northeast

PeriOp director Southeast

OR Manager Midwest

Frontline mgt/team leader Mountain

Frontline team/hands on care West

International

Where do you work?

Ambulatory surgery Where are you in your lean journey?

Small community hospital Not started, only heard about it

Sizeable healthcare network Education, some dabbling in projects

Free standing hospital In process, successes & challenges

Ingrained and embedded in culture

4

LVHN Lean History Lean education, standardize A3 problem solving

3rd value stream – Access to Care

Collaboration Healthcare Value Network

CEO charge: explore improvement model

Transformation: tools to system thinking

First Embedded Coach

Network adopts Lean methodology

Two pilot Value Streams

● In Hospital Patient Flow

● Perioperative

Ongoing spread of Lean-depth and breath

Strategically positioned Lean team to transform network

Evolution of Visibility Walls: Network wide Alignment and Collaboration

Introduction Daily Management System

2007 2009 2011

2006 2008 2010 2012

5

Healthcare Spending as % of GDP

18

16

14

12

10

8

6

4

2

0 1960 1970 1980 1990 2003 2007

% o

f G

DP

6

9/23/2013

2

What is Lean?

▪ Elimination of waste through a five step

process:

1. Define customer value

2. Define the value stream

3. Make the value flow

4. Pull from the customer back

5. Strive for excellence

7

IDENTIFICATION OF VALUE AND NON-VALUE ADD WORK

Identification of Waste

8

Value Is:

▪ Defined from customer’s perspective

▪ What the customer wants from the process

▪ What the customer is willing to pay for

▪ Value = Quality / Cost

9

Non-Value Add Is:

▪ Everything the customer does not want

▪ Everything the customer is not willing to

pay for

10

Value Add vs. Non-Value Add: Increasing Value to Customers

What are examples of each of the four areas?

Value Add Non-Value Add

Necessary What we are here to do! State/TJC requirements?

Not Necessary

Patients require/want but we don’t see need

WASTE! Use lean tools to eliminate to increase capacity Each work element typically waste

11

Focus of Improvement

Improvement will be easier and more likely to succeed by focusing on the non-value added activities and removing them.

Total Flow Time for Patient

90 % NVA 10%

Value

Adding

Arrive Leave

12

9/23/2013

3

8 Wastes in Healthcare: “U-WIT-D-MOP”

Unused Human Potential: Untapped creativity/talent/injuries

Waiting: patients/providers/material

Inventory: stacks of work/piles of supplies

Transportation: transporting people, paperwork

Defects: wrong information/rework

Motion: finding information/double entry/searching

Overproduction: duplication/extra information

Processing: extra steps/checks/workarounds

13

Examples of the 8 Wastes

Unused Human Potential ▪ Physicians transporting patients

▪ Support and Technical Partners taking patients to front door

Waiting ▪ Waiting for transport to go to or return from

any location

▪ Discharge transportation

▪ Physicians waiting for test results ▪ Waiting for D/C instructions

Inventory ▪ Not having right supplies in the right place at

the right time

▪ Patients waiting for bed assignment

▪ Lab samples batched

Transportation ▪ Moving patient to tests

▪ Equipment transport

Defect ▪ Re-sticks ▪ Medication errors

▪ Hospital Acquired Infections

Motion ▪ Trying to find workspace (i.e. computer terminal)

▪ RN has to go to more than one source to find info

▪ Multiple locations for information (no cross-talk)

▪ Searching for materials, information

Overproduction ▪ Maintaining paper and electronic sources of

information

▪ Returning multiple times to transport a patient who isn’t there

▪ Picking case that has been cancelled

Processing ▪ Nurse taking extra steps (i.e. keep coming back

to complete assignment)

▪ Medication and Allergy reconciliation process

▪ Lack of standardized care plan

14

How to Identify Waste – “Gemba”

▪ Follow patients

– From admission to discharge

– What happens?

– What doesn’t happen?

– Where does waiting occur?

▪ Follow colleagues

– What are they doing?

– Why are they waiting?

– Are they doing things that don’t add value?

*Gemba = work place 15

Why Do Colleagues Walk?

▪ Routine work

– Walking between

patient rooms

▪ Unplanned, reactive

work

– Searching for

supplies, meds

▪ Have work methods

and practices been

designed or have

they just evolved?

▪ With Lean, we

question everything

– is there a better

way?

16

Handout of Gemba Visit

Does your walk have a purpose? Packet 17

How to Reduce Waste

▪ Focus on actions within the immediate

Gemba.

▪ Focus on “quick wins.”

▪ Reducing waste in the Gemba means we

join the team of 11,500 problem solvers in

the Network.

18

9/23/2013

4

Things to Remember About Waste

▪ Waste is anything other than the minimum

amount of resources that are essential to

add value required by the customer.

▪ Waste is a symptom, NOT a cause.

▪ Waste points to underlying problems within

the system.

▪ We need to find and address the

underlying problems. 19

Group Exercise

▪ Individually identify 3 value add activities and 3 non-value add activities at your gemba – 5 minutes

▪ Break into groups of 2 or 3, spend 10 minutes:

– Share examples

– Discuss how non-value add activities relate to value to our customer

▪ Report out for each group – 10 minutes *Gemba = work place

20

BASIC LEAN TOOLS:

6S – Standard Work

21

Underlying Principles of 6S

A place for everything

AND

everything in its place

Detect normal from abnormal…..

AT A GLANCE

22

Sequence for 6S

▪ Sort

– Remove items not needed daily (red-tag process

▪ Set in Order

– Label items and make it obvious where they

belong

▪ Shine/Sweep

– Clean and inspect everything, inside and out

– Visually sweep area to make sure everything is

in its place 23

Sequence for 6S (cont)

▪ Safety

– Required safety information is posted

– Exits and emergency equipment are clearly marked and functional

▪ Standardize

– Establish policies and standard work to ensure 6S

▪ Sustain

– Training, discipline, daily activities, self-audits

24

9/23/2013

5

25

Standard Work: What is it?

▪ Least waste way to do work or perform a

service

▪ Set of procedures executed consistently

▪ Basis for all continuous improvement

activities

26

6S STANDARD WORK

Numbers Exercise

27

Case Studies

▪ ASU to OR

– Difficult IV starts moved earlier

▪ Move from staging to holding room

– “First come first served?”

▪ OR holds

– Staffing analysis standard work

28

What Can You Do?

▪ Waste walk with staff?

▪ 6S audit?

▪ Stand and look at area?

Packet waste walk form

Go do!

29


▪ Introductions



Break

▪ VSM Lunch


– A3 Thinking

Break

▪ Culture Change 30

9/23/2013

6

VALUE STREAM MAPPING

Learning to See Opportunities

31

Value Stream Mapping Steps

▪ Agree on what process to study, logistics, team

▪ Agree on the current situation

▪ Agree on a shared vision of the future lean state

▪ Agree on how to implement the future state plan

▪ PDCA – repeat again

Preparation

Current State

Planning

Future State

Implementation

PDCA = plan, do, check, act 32

What is a Value Stream?

▪ A value stream is all the steps (both value-added and non-value-added) that are required to complete a product or service from start to finish.

▪ Addresses value, flow, work elements and supports continuous improvement.

Triage Discharge Treat Physician

Assess Nurse Assess

Patient sick

Patient well

Value Stream

33

VSM Parts

Timeline/Heartbeat & Summary

Information flow Beginning End:

Customer

Process Boxes

Process Data Boxes

34

VSM Improvements

Objective of VSM is identified improvement ideas and an actionable roadmap

The conversation is key!

Implement Daily

management

Implement Std work for

staffing

Implement Std work for

overflow

Apply 6S for supplies/

carts

35

Flow Inefficiencies and Countermeasure Examples

Too many handoffs

Fluctuations in work volume/type

Fluctuations in how staff handles pace of work

Interruptions to get supplies

Rework

Poorly defined expectations

Combine steps

Separate standard process from “special work”

Standardize work

Create point of use stores

Identify and eliminate

Feedback to understand customer expectations

36

9/23/2013

7

Future State Questions

1. What work areas need better organization?

(Use 6S tool)

2. What work areas need better daily metrics so the status is more obvious?

(Use Visual Management/ Daily Management System tools)

3. What work area has too much variation?

Where is the process not consistently done the same way by all staff?

Where is the quality defect rate too high?

Where are cycle times too long?

(Use Standard Work & A3 problem solving tools)

4. Where is there too much time spent changing from one process to another

(Use Turn Over time/Set-up time reduction tool)

5. Where are there material stock-outs?

Where is there too much inventory?

(Use Material Pull tool)

37

VSM Process We Used

Current State Map with vision

Prioritized opportunities

Roadmap for actions

Developed detailed charters

Plus: Daily updates with leadership staff

Identified opportunities

38

Case Studies

▪ PACU – Felt powerless and wanted mgmt to fix things

▪ LVH-Muhlenberg – ASU felt powerless as mgmt was telling them what to

fix

▪ Lessons learned: – Think about timing to implement

– Prioritize

– Use visual mgmt for check ins

– Identify gaps between that we think happens and what happens

– Team makeup 39

What Can You Do?

▪ Use your lean coach/consultant and create

a current state VSM, future state VSM and

an action plan

But with help!

Go do!

40


▪ Introductions



Break

▪ VSM Lunch


– A3 Thinking

Break


DAILY MANAGEMENT AND A3 THINKING

42

9/23/2013

8

The Daily Management Diamond

▪ Visibility walls

▪ Daily metrics

▪ Problem-solving

▪ Huddle

Review Brochure

43

Daily Management:

▪ A tool for alignment and

focus

▪ A way to drive

accountability

▪ Proactive problem solving!

▪ Just monthly metrics

▪ Arts and charts

▪ A mechanism to

assign blame

Consistency and Dedication

Is: Is Not:

44


▪ Visibility walls

▪ Daily metrics

▪ Problem-solving

▪ Huddle

Review Brochure

45

What are Visibility Walls?

▪ Visibility walls are monthly metric boards

with key department metrics that are

aligned to network goals

– P, S, Q, C, G

▪ They are monthly metrics that track data

trends and utilize A3s for problem solving

▪ Teams meet at the walls monthly to review

issues

46

Moving out is better

Mo

ving o

ut is b

etter

Is Is not How to be green

Vis

ibili

ty W

all

Visibility Wall up and maintained

Network format visibility wall in place

A daily metrics board A daily huddle board

Metrics posted and current by the 10th of each month

Supports visual management

color coded with red / green clear goal lines with an indicator of better/worse

Black and white chart Additional "non-approved" colors

Follow standard color coding. Outside eyes can stand back from board and clearly determine if team is on track

Team reviews Wall regularly to provide updates on A3s

A3 plans for specific metrics are posted & up to date Verbal A3s at huddles

A3s indicate that the actions taken have influenced the metrics towards the goals & A3 is less than 3 months old.

See Your Brochure

47

Visibility Wall Checklist

Is the Network format wall in place?

Is it color coded with clear goals?

Is the trend data current?

Are A3s posted and up to date?

Did the A3 work improve the metrics?

Packet 48

9/23/2013

9


▪ Visibility Walls

▪ Daily Metrics

▪ Problem-Solving

▪ Huddle

49

It Starts With Alignment

Metric Visibility Level Engagement

Visibility Level Engagement

Hospital- acquired infections

Executive level metric reviewed monthly

• Front-line staff generally not involved or engaged

Hospital- acquired infections



Catheter -associated urinary tract infections (UTIs)

Dir / admin. level metric reviewed monthly

• Aligns w/ exec. metric • May be reviewed at

visibility wall with front-line staff

Hospital -acquired Infections



Catheter -associated urinary tract infections (UTIs)

Dir / admin. level metric reviewed monthly

• Aligns w/ exec. metric • May be reviewed at

visibility wall with front-line staff

Catheters in > 2 days

Front-line staff metric reviewed daily

• Front-line staff engaged • Completely transparent • Can “course correct” as

needed • Increases engagement

and staff

Reactive

Proactive

50

What are Good Daily Metrics?

▪ Engaging to front-line staff

▪ Easy to track and measure and impact

▪ Aligned to visibility walls

▪ Lead to improved results

It’s all about the problem solving!

51

Action Plan Item # Date Issue Action Who When Update

Living Pareto Chart for (unit/dept)______________ Data start date:___________

Inci

de

nts

20 19 18 17 16 15 14 13 12 11 X 10 X 9 X 8 X 7 X 6 X 5 X X 4 X X X 3 X X X 2 X X X X 1 X X X X X

Cat

ego

ry

Prob

lem

1

Prob

lem

2

Prob

lem

3

Prob

lem

4

Prob

lem

5

LVHN- Trend Metric

xyz

me

tric

100%

90% X X X X X

80% X X

70% X X

60%

50%

40%

30%

20%

10%

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Bett

er

Target greater than 90%

Trend Chart How are we doing compared to goal?

If not meeting goal — What was the reason?

Action Plan Who is doing what by when?

Daily Metric Components

Packet with each chart 52


Mo

vin

g o

ut

is b

ette

r

See Your Brochure


Dai

ly M

etr

ics

Daily Metrics posted & maintained

Tracking metric from the previous day or that day Metric is up to date Monthly metric

Trend chart shows metric is recorded regularly through the month

Team reviews regularly at huddles

Team meets daily as scheduled

Monthly staff meeting to review visibility wall

Key staff members meet regularly

Metrics used to facilitate problem solving

Pareto chart indicates issues related to missed metrics

Only a trend chart Only a white board to capture a Single issue for the day

Metrics indicate actions taken by frontline team are impacting results

53

Daily Metric Board Checklist

Is the Daily Metric board in place and the

format correct?

Is the trend data current with a goal?

Can you tell status of a metric and

reasons for any misses?

Are action plans posted and up to date?

Have actions improved the metrics?

Packet 54

9/23/2013

10



▪ Daily Metrics

▪ Problem-Solving

▪ Huddle

55

Problem Solving

▪ Problems discussed by team & actions

recorded

▪ A3 forms used for key metrics

▪ Problems discussed by frontline staff and

actions recorded

56

Pro

ble

m S

olv

ing


Problems discussed by team & actions recorded

Manager leads board review. Manager and frontline staff discuss issues

Manager directs frontline staff what to do

Some level of action recording (white board recording)

A3 forms used for key metrics

Actions are recorded with specifics including names and dates Team decides when actions are required for a metric miss

Discussion of problems without capturing the actions

Formal action plan used to record what/who/when/why

Problems discussed by frontline staff & actions recorded

Frontline staff leads board review & discussion, manager listens and participates as needed Manager only discussion

Frontline staff fills in action plan used to record what/who/when/why

See Your Brochure

Mo

vin

g o

ut

is b

ette

r


57

▪ Make adjustments

▪ Standardize

▪ Teach others

▪ Go to the gemba

▪ Ask why

▪ Discover root cause

▪ Measure outcomes

▪ Fail fast and learn

▪ Develop countermeasures

▪ Experiment

▪ Lean Tools 58

A3 Thinking

What is it?

▪ A tool for collaborative, practical problem-

solving

What does it do?

▪ Promotes continuous improvement

59

Seven Elements of A3 Thinking

▪ Logical Thinking Process

▪ Objectivity

▪ Results & process

▪ Synthesis, Distillation, & Visualization

▪ Alignment

▪ Coherency & consistency

▪ Systems viewpoint

60

9/23/2013

11

III. GOALS/TARGETS

What specific outcomes (in measurable or identifiable

terms) are required?

IV. ANALYSIS

What is the root cause(s) of the problem?

- Choose the simplest problem

solving-analysis tool (5-Whys, Fishbone Diagram,

Process Analysis Tree, etc.) that clearly shows the

cause-and-effect relationship.

VII. FOLLOW-UP

What issues can be anticipated?

- Ensure ongoing PDCA.

- Capture & share learning.

TITLE: What are you talking about? OWNER/DATE:

I. BACKGROUND V. PROPOSED COUNTERMEASURES

Why are you talking about it?

What is the business problem you are trying to solve?

What is your proposal to reach the future

state, the target condition?

How will your recommended

countermeasures affect the root cause to

achieve the target?

II. CURRENT CONDITIONS

Where do things stand today?

- Show visually using charts, graphs,

drawings, maps, etc. to make the problem clear.

What is the Problem?

VI. PLAN

What activities will be required for

implementation and who will be

responsible for what and when?

What are the indicators of performance

or progress?

- Incorporate a Gantt chart or similar

diagram that shows actions/outcomes,

timeline, & responsibilities. May

include details on specific means of

implementation5 why Standard work Process mapping

6S Standard Work

PDCA

Daily metrics

61 Packet



▪ Daily Metrics

▪ Problem-Solving

▪ Huddle

62

Huddles

▪ Problem solving:

– Discuss critical issues

and emerging events

– Anticipate outcomes

and likely contingencies

– Assign resources

– Express concerns

Problem solving huddles are not the same as clinical huddles! 63

Dai

ly H

ud

dle


Regular Time Team has scheduled (regularly selected time) for a huddle

A "soft" time that changes daily and is not followed

Meet at the scheduled time on a regular basis

Huddle on schedule and follows standard format

Staff knows when huddle occurs. Staff knows who will cover board each day. Staff follows script*

Open ended talk without a script A meeting at the board with talking but not following a plan

Team meet at the scheduled time. It is clear who talks to the board, script* followed

Two way communication/ interactive

Back and forth questioning Use of 5 why to understand root cause Manager only talks

Dynamic conversation focused on problem solving

i

Mo

ving o

ut is b

etter


See Your Brochure

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Huddle Checklist

Start on time

Have each process owner review their metric

How does that metric impact the patient/ team

Review process for problems

Record issues

Create plan as appropriate

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Conversations at the Gemba

▪ Look

– What are they measuring? Why?

– How are they doing?

▪ Listen

– Are they problem solving? Is there a plan?

▪ Ask, coach, celebrate

– Relative to their metrics and actions

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Two Types of Bird Watchers!

▪ No real plan; just “look”

▪ Any outcome is good

▪ Reactive

Opportunistic Bird Watcher

▪ Have a goal and a plan

▪ Desired outcome is best

▪ Proactive

Purposeful Bird Watcher

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Daily Management Lessons Learned

▪ If you can see it, you can fix it.

– Act on actions

▪ If it’s important to you, it will be important

to staff.

– Be seen seeing (looking at the board)

▪ Act your way into a new way of thinking.

– Regular huddles

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What Can You Do?

▪ Create a board

– Align to goals

– Don’t underestimate the power of engagement

– Focus on what they can change

– Identifying the problems

▪ Start huddles

▪ Utilize checklists

▪ Schedule executive gemba walks!

Go do!

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▪ Introductions



Break

▪ VSM Lunch


– A3 Thinking

Break


CULTURE CHANGE:

Putting it all together

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PACU Daily Management Process

▪ Daily review at a stand up meeting

– Trends, issues, actions

▪ Two metrics:

– OR Holds and

– Percent staff that received break

– The “and” not the “or”

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The “Before” Culture

▪ Staff saw problem as beyond their control

– Someone has to fix it for us

– More FTEs

– Tell us what you want us to do

– Woe is me

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The “After” Culture

▪ Staff now sees problems and owns

solution

– Past: Last spring “woe” is me

– Now: What can we do to fix this?

– Conversion from renters to owners

– How it has helped PACU grow

– “It doesn’t feel as busy”

– 15% volume increase

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A-B-C of Culture Change

▪ Implement Action

– Implemented daily metrics on two key metrics

– Tracked regularly

▪ Create Behavior

– Reviewed at new daily huddle

– Asked what happened day before

– Did we hit goal? What are we doing about it?

▪ Change Culture

– Staff became proactive at problem solving

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Case Studies

▪ Review daily huddle process, talk about “engagement score”: 2 of 12 is not good, also we need to address “what would make your day better?

▪ Foster engagement vs. fizzle – As many people as possible, experiment and risk.

Fizzle: too much tracking and not enough problem solving and changes

– Fizzle: to quick to formulate answers.

– Block in holding room – could have assumed it was anesthesia. Real problem was they were not on unit first.

▪ Standard work on staffing

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What Will You Do Monday?

▪ Do a waste walk?

▪ Do a 6S audit of an area?

▪ Stand and observe for an hour?

▪ Create a Current State/Future State

Map/Roadmap? (use a lean coach)

▪ Create a Daily Metric board and Huddle?

▪ Start an A3 on key issue?

Quick vote – raise your hand for the one you will try!

Go do! Alone?

With your team?

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▪ Introductions



Break

▪ VSM Lunch


– A3 Thinking

Break


Questions?

Contact information: Jodi Koch- 484-884-2555 [email protected] Andrew Dordal- 484-884-0215 [email protected]

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Contact Information:

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APPENDIX

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Creating a Current State Map

▪ Define process steps – quick review

▪ Walk the flow backward noting – interview staff

– Information flow

– Process steps

– Performance metrics

▪ Draw map with data boxes, information flow, timeline

– Supplier, customer

– Metrics and quality

– Accurate data

▪ Calculate timeline with process time and lead time

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Specific VSM Steps

▪ Overview of area/walk through of process

▪ Build process steps – Leader should know these in advance

▪ College process steps, data, and info flows – interviewing as team – Walk flow backward after initial overview

– Interviewer (using some/all current state questions)

– Data recorder (on data box sheet) – count inventory levels – Information flow, process steps, metrics

– Mapper (write out steps)

– Time keeper (5-7 min/interview)

▪ Observations of process/time studies – Break into pairs and conduct time studies as needed

▪ Calculate timeline with process time and lead time

▪ Create VSM – good to do close to Gemba – Share data collected/fill in missing data

▪ Review as a team 82

Questions for Current State

1. Briefly describe your work process.

2. How do you know what to do next in your process? – Keep this question as open ended as possible.

3. Where does material or patient come from and go to?

4. Do you complete your process the same way every time? – You may ask about specific variation driven by patient conditions

5. How long does your process usually take? (process time or “touch time”)

6. How many associates (operators) are involved in completing your process?

7. How many charts/patients/units are waiting to be worked? What is wait time?

8. What computer systems or software are used at this process step?

9. What are significant issues like rejects, wait times, equipment shortage, etc.

– Consider asking how often this occurs if percent is hard to determine

10. What is at least one critical improvement to your process? – Quality issues? Productivity issues? Corrections/clarifications?

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8 Wastes – Walk Form

Unused Human Potential:

Waiting:

Inventory:

Transportation

Defects:

Motion:

Overproduction:

Processing:

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6-s checklist # of y's: 25 = % date · sort (get rid of what's not needed): - unnecessary...

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