Extending Your Lean Journey through Design and Construction Projects Nick Masci, Dacon Paul Fallon, TRO JB January 22, 2013
AGENDA Introductions and Definitions Concepts Strength of cross collaboration Lean as a Mechanism to Great Decision Making Moving from Lean Tools to Lean Mindset Design as Rapid Prototyping for the Future State Case Studies Project Planning A3 Case Study Maximize Visualization / Reduce Steps Heywood Hospital Case Study Rapid Improvement Events MGMC Case Study Process at a Glance Simplified VSM BID-Milton Ortho Center Case Study Lean 2P Full Scale Prototyping BIDMC Pharmacy Case Study Optimizing Stakeholder Input L&M Cancer Center Case Study Questions / Comments Massachusetts ac Hospital Lean Network
INTRODUCTIONS AND DEFINITIONS Nick Masci, LEED AP Project Executive at Dacon Corporation Education - Villanova University, BS, Naval Science Minor - AME Lean Body of Knowledge nmasci@dacon1.com Cell: 781.727.6595 LinkedIN: www.linkedin.com/in/nickmasci/ Twitter: @nickmasci
INTRODUCTIONS AND DEFINITIONS Lean = Systems Approach to Solving Problems with an eye towards Value Job = Work + Kaizen
INTRODUCTIONS AND DEFINITIONS Paul E. Fallon Senior Associate at TRO JB Architect and Lean Facilitator Education M. Arch, MIT MSCE Project Management, MIT Six Sigma Green Belt, Villanova pfallon@trojb.com fallonpaule@gmail.com LinkedIN: www.linkedin.com/in/paulefallon/ Twitter: @paulefallon
INTRODUCTIONS AND DEFINITIONS Lean = Custom Product Produced on Demand
CONCEPTS Strength of Cross Collaboration Lean concepts relevant to many process analyses Lean applications outside our direct business help us understand its breadth and capacity
CONCEPTS Lean as a Mechanism for Great Decision Making If it s important, make it visual Consistent application of scientific method
CONCEPTS Moving from Lean Tools to Lean Mindset Question Silos Identify users in broadest sense Integrate Technology Standardize Planning Deep Definition of Sustainability
CONCEPTS Design as Rapid Prototyping for the Future State Design new facilities to enhance preferred operational model Test proposed operations in models and mock-ups Tweak operational model and design in tandem Standardize Planning Optimize Flow / Reduce Travel Organize Supply Chains
CONCEPTS
CASE STUDY - ACCUROUNDS
CASE STUDY - ACCUROUNDS Create Alignment by Setting Expectations INSPIRATION AND GUIDANCE Shingo Prize Model Guidelines www.shingoprize.org
CASE STUDY - ACCUROUNDS
CASE STUDY - ACCUROUNDS My Value Stream is Important too Supply Chain Integration
CASE STUDY - ACCUROUNDS
CASE STUDY - ACCUROUNDS
CASE STUDY - ACCUROUNDS Root Cause Analysis Pick your Issues (Think OBEYA) Attack the biggest issue Consider creating an OBEYA (Big Room) Since this report, Owner has nailed budget Shift to Target Value Design = Greatest Focus on Max Value Creation
CASE STUDY - ACCUROUNDS Implementation Plan
CASE STUDY - ACCUROUNDS Signature Block. Every Week. Buy In! Big departure from current industry standard practice. Send meeting minutes. Participants have prescribed time to voice concerns or imply tacit improvement doesn t work! Hesitant at first then something wonderful happens pride of ownership. I WANT MY NAME ATTACHED Roll in other stakeholders as project progresses.
CASE STUDY HEYWOOD HOSPITAL ED Maximize Visualization / Reduce Steps Value Stream Mapping Exercise Identified key elements of ED Treatment Room work cell Visibility became key design driver Focus on supply chain distribution
CASE STUDY HEYWOOD HOSPITAL ED Impact on Planning Large central station with direct visibility to all spaces Direct connections between Station and Trauma Par level Procedure cart in each ED room Specialty supplies remote but connected to Trauma
CASE STUDY - HEYWOOD HOSPITAL ED Heywood Hospital Emergency Department Gardner, MA
CASE STUDY MAINEGENERAL MEDICAL CENTER MGMC PROCESS MAPPING EVENT - Imaging Patient Hold - February 15, 2011
CASE STUDY MAINEGENERAL MEDICAL CENTER Process Mapping Event Focused Investigation of one specific problem Our Question: How do we care for Imaging Patients who need Pre- or Post-Procedure Support? How many pre- / post-procedure spaces do we need? Do we have both stretcher and chair spaces? What are key adjacencies to imaging procedure areas? Introductions Name and position What is your connection patients having an imaging procedure?
CASE STUDY MAINEGENERAL MEDICAL CENTER Histograph of Existing Conditions
CASE STUDY MAINEGENERAL MEDICAL CENTER Histograph of Condensed Current State Conditions
CASE STUDY MAINEGENERAL MEDICAL CENTER Process Flow Concepts we will use Today Value Stream Map Graphic depiction of the process of low acuity ED patients Current State map will outline how we process these patients now Future State map will describe how we want to do this in the future Parking Lot The place to land any issues that come up that are not specific to the questions at hand May be opportunities for future process mapping events
CASE STUDY MAINEGENERAL MEDICAL CENTER Value Stream Map Basics Blue Diamond Process Initiation Patient arrives at Imaging Department Ambulatory Outpatient ED referral Inpatient Green Square a Task that is Performed Assign task a name, a duration, a person Red Square Waiting Time Assign a duration Yellow Diamond a Decision Fork Define the options Blue Square Process Completion Patient leaves imaging area
CASE STUDY MAINEGENERAL MEDICAL CENTER Data Collected for this Rapid Improvement Event Culled from Waterville and Augusta Imaging Services Represents a busy day for each service Includes all procedures that will take place in NRH CT Ultrasound MR Diagnostic Radiology Interventional Radiology Mammography Nuclear Medicine
CASE STUDY MAINEGENERAL MEDICAL CENTER CT
CASE STUDY MAINEGENERAL MEDICAL CENTER CT 53 cases total ED and Inpatient cases skip Prep for Procedure Various cases skip Post Procedure Registration to Prep (26 cases) Average = 10 minutes Range = 0 to 20 minutes Prep for Procedure Average = 29 minutes Range = 4 to 132 minutes Procedure Average = 10 minutes Range = 1 to 19 minutes Post Procedure (29 cases) Average = 15 minutes Range = 0 to 30 minutes
CASE STUDY MAINEGENERAL MEDICAL CENTER Combined Totals Pre-Procedure Holding 132 cases total 53 CT 6 US 30 Diagnostic Radiology 19 Interventional Radiology 8 Nuclear Medicine 6 Mammography 10 MR Post-Procedure Holding 68 cases total 29 CT 6 US 3 Diagnostic Radiology 19 Interventional Radiology 0 Nuclear Medicine 6 Mammography 5 MR
CASE STUDY MAINEGENERAL MEDICAL CENTER Data Projections for this Process Mapping Data is based on all existing Augusta and Waterville cases Assume growth inherent as cases will remain at Waterville 200 Patients per day using Imaging Holding
CASE STUDY MAINEGENERAL MEDICAL CENTER Consider Range of Possible Solutions Where can Savings or Improved Care Result in Sharing Resources? Where do clinical / staffing needs dictate clear separations? Propose Answer to our Key Questions: How many holding spaces are required? How many stretcher vs. chair spaces? What are primary relationships to imaging modality areas?
CASE STUDY MAINEGENERAL MEDICAL CENTER Workshop Methodology Logistics / Introductions 15 minutes (are we on time?) Group Exercise Current State map, divided by modality 45 minutes Group Brainstorm Identify value and efficiency in current state process Identify key value tasks to be included in all process maps Identify which alternative processes to map 30 minutes Break / Stretch / Small Group Assignments 10 minutes
CASE STUDY MAINEGENERAL MEDICAL CENTER Workshop Methodology Group Exercise Future State Map for Alternative Solutions 30 minutes Interim Report in Place 1 minute report from each team 10 minute feedback on progress Group Exercise Complete Future State Map for Alternative Solutions 20 minutes Come Together Group Report Out Consensus Identify Follow-Up steps 20 minutes
CASE STUDY MAINEGENERAL MEDICAL CENTER Four Hours of Collective Work Pass
CASE STUDY MAINEGENERAL MEDICAL CENTER And We Develop a Flow Diagram of the Future State
CASE STUDY BID MILTON ORTHOPEDIC CENTER Total Knee Replacement Process at a Glance 15 pages, hundreds of steps Set Appointment by Telephone Arrive at Hospital - Find MOB Check In Patient Experience Key Points Busy Office Not Enough Phone Lines Collect All Information 2 Weeks to get Appt. Insurance Barrier No Workman Comp Give Directions No Standard Terms Driver s License More Forms Lack of Parking. Lot? Rapid Response Tension about Ride No wheelchair in MOB Where to go? Entrance? Duplicate Info Double/triple book Extra chairs in hallway Interpreter Unease 3 Admin 1 Window Multi Trips to Window Pecking Order pissed off. 2-4 window visits Patient Workarounds
CASE STUDY BID MILTON ORTHOPEDIC CENTER Design Scorecard LEAN Thinking Layout Rank (0-5) T1 T2 T3 Floor Layout and Equipment Permits Easy Patient Flow 4 4 3 Think of Future Use, but Design for Near Term with Additive Capacity 5 3 2 Make Equipment Easy to Disconnect and Relocate 4 5 3 Flexible Multi-Usage Areas & Equipment that are Easily Reconfigured 5 5 4 Make the Range of Staff Narrow and Compact 3 3 5 Layout AND Equipment Allow Staff to Move Easily 2 4 2 Remove Wasted Motion from Equipment 2 4 3 Use Vertical Space to Configure Equipment (Townhouse not Ranch) 3 4 4 Layout for Laminar Flow, NOT Zigzagging or Backtracking 3 5 5 Schedule Resources According to Patient Need 2 3 3 Design Tools and Instruments for Quick Changes 5 3 2 Combine or Link Operations to Avoid Queing 4 4 1 Use Multiple Lines to Avoid Confusion 4 3 3 Build Quality at the Source into Each Operation 2 2 2 48 52 42
CASE STUDY BID MILTON ORTHOPEDIC CENTER Design Scorecard Bringing Services to Patient Layout Rank (0-5) T1 T2 T3 Zero Waiting 3 4 3 Zero Walking 3 2 3 Zero Transport 3 2 2 Zero Duplication 3 3 1 Zero Correction 4 3 3 Zero Misunderstanding 4 4 2 Zero Being Left Alone 4 4 4 Zero Handoff Confusion 3 4 4 Zero Rushing 2 2 4 Lean Thinking Sub-Total (previous page) *Average Score = 3.7 48 52 42 Bringing Services to the Patient (this page) *Average Score = 3.2 29 28 26 77 80 68
CASE STUDY BIDMC PHARMACY Lean 2P Events Production & Process Intensive exercise to establish the physical parameters of a functional area 3 to 5 days All constituents Mapping and diagramming Full Scale mock-ups Report Out
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY Existing Conditions Pharmacy in four locations Clean room has to remain
CASE STUDY BIDMC PHARMACY Proposed Plan Primary work cells around Dispensing machines Receiving moved to front IND incorporated in main Pharmacy Ancillary work in outlying cells Circular path for water spider
CASE STUDY BIDMC PHARMACY
CASE STUDY BIDMC PHARMACY Post-Occupancy Evaluation Work cells intact Challenge I getting the supply levels manageable It works much better than I ever anticipated Sonya, Pharmacy Tech There has been a precipitous drop in our medication errors going to the floor David Magnon, Asst. Dir. Pharmacy
CASE STUDY L&M CANCER CENTER Optimizing Stakeholder Input Kick-off design event 3 consecutive days 60 users from three separate practices
CASE STUDY L&M CANCER CENTER Lean Concepts Utilized All stakeholders in one place Guiding Principles / Critical Success Targets Bubble Diagramming Mock-Ups Spaghetti Diagramming Check In / Report Out
CASE STUDY L&M CANCER CENTER Guiding Principles / Critical Success Targets Four facilitated groups Key Words / Brainstorming Frequent check-in and editing Consensus on critical targets
CASE STUDY L&M CANCER CENTER Bubble Diagramming Site Scale with clear platform to create two story Building scale with individual cutouts Capability to make more / different cut-outs
CASE STUDY L&M CANCER CENTER Mock-ups Simultaneous evaluation Exam and Infusion spaces Flexibility on proportion and closure Placement of equipment and furniture
CASE STUDY L&M CANCER CENTER Spaghetti Diagramming Map Multiple flows Measured Travel Distances Identified Traffic Jams
CASE STUDY L&M CANCER CENTER Check In / Report Out Short duration of activities Change of scale of activities Regular interface among the four groups
CASE STUDY L&M CANCER CENTER
CASE STUDY L&M CANCER CENTER
CASE STUDY L&M CANCER CENTER
QUESTIONS / COMMENTS Questions / Comments
Extending Your Lean Journey through Design and Construction Projects Nick Masci, Dacon Paul Fallon, TRO JB January 22, 2013