What Healthcare can learn from fixing cars?

Applying TPS to System Design

Dr Tan Yung Ming

Contents
Learning objectives Background & History of Toyota The Lean or Toyota Production Concepts Case Studies Tips to start your Kaizen Project Conclusion Q&A

Learning objectives
Appreciate the philosophy and concepts behind Toyota Production System (TPS) or Lean Appreciate how TPS is applied to Healthcare through case studies How to start your very own TPS Kaizen project.

The Origins of Lean

Lean methods originate from Toyota Production System (TPS)
Lean a more American term Optimal way of producing goods & services by removing or minimising of waste, variability and inflexibility.

History of Toyota
1918: Sakichi Toyoda founds the Toyoda Spinning and Weaving Company. 1929: Kiichiro Toyoda traveled to Europe and USA to investigate automobile production

1937: The Toyota Motor Corporation (TMC) is founded.

1930 - 1940: Kiichiro Toyoda implements the Toyota Production System (TPS).

Learning about Mass Production

Henry Fords Assembly line method using moving conveyor belts (1913). Fords Model T car assembly time: reduced from 12hrs to 93 min. By end of WWII, Fords factory could assemble not just cars, but one B17 bomber every 63 min. Toyota was only a small start up, but it learned fast!

In 2004, Toyota overtakes Ford as No 2

In 2007, Toyota overtakes GM as World No.1

2008-2009Financial Crisis
With the financial crisis, the Big Three automakers in US are collapsing. GM, Ford and Chrysler have received > US$25 billion in government aid, but GM/Chrysler are facing bankruptcy. Toyota suffered its first loss in 70 years US$5.9 billion. However, it retains a strong balance sheet (US$25 billion in cash).

2010 Largest Recall in Toyotas History

Trigger: 4 deaths from one accident with suspected unintended acceleration

Media hype resulted with increasing consumer complaints. Outcome: Millions of cars recalled

CEO Akio Toyodas response

Self-reflection & acknowledge mistake The past few weeks, however, have made clear that Toyota has not lived up to the high standards we set for ourselves. More important, we have not lived up to the high standards you have come to expect from us. I am deeply disappointed by that and apologize. As the president of Toyota, I take personal responsibility. That is why I am personally leading the effort to restore trust in our word and in our products. Akio Toyodas letter (NYT) Stop to fix mistakes US production plants stopped for months, Recalls to fix issues Take action Kaizen teams headed by CEO
Global operations review Quality control review ( + external expert review) Emergency Profit Improvement Committee

Communication initially criticised for being slow to communicate, Toyota is stepping up transparency n will publish all technical details of the recall fixes and bugs.

Toyota climbs back up..

Following the core TPS principle of self-reflection, Akio Toyoda frankly stated that Toyota in decline due to - Reckless expansion - Deviation from basics
New drive to re-examine the errors and correct them immediately. R&D, quality management efforts are re-examined.

Toyota regains profitability in 2011.

What is Lean or TPS?

Misconceptions about Lean or TPS Management

TPS methods are often misunderstood by people.

To many,
TPS = cost control and cuts, improve operational efficiency

What Happened?
Many companies grow out of control Wasteful practices Slow to adapt

So what is being Lean about?

Is it from this .

Into this?
Misconceptions Cut everything Wage cuts Job cuts Massive Restructuring Outsource everything But Lean is NOT about being anorexic, rather .

True Definition of Lean

As is . To be

Lean = KillerEfficiency Agile Adaptable Healthy growth

Is TPS relevant to healthcare?

Healthcare institutions are huge - Processes are complex, inefficient - Multi-disciplinary staff, - Thousands of care components affecting a single patient - One systemic error can cause large damage downstream - Bureaucratic policies - Costs always escalating!

TPS is about streamlining service delivery NOT about treating humans like cars.
TPS is about creating value for the customers.

What Patients want from their Providers

Based on AH/KTPH patient feedback over years

Respect for patients dignity Clear and accessible information Integrated care and services Consistent, good quality care & services Cost effective care

Value Add (VA)

Diagnose Treat Advise

The Patient Value-stream map

What does a Customer or Patient Need in healthcare?

Diagnosis

Treatment

Advice

Applies to typical healthcare providers eg. Hospitals, clinics Before building any Healthcare IT systems, we shld consider this value stream before development Ask what is the value of the system to the patient?

Courtesy of Khoo Teck Puat Hospital

Key principle in TPS: Reducing waste or muda

The 7 deadly wastes: Defects Overproduction Transportation Waiting Inventory (unused especially) Motion Overprocessing

Case Study 1 Optimising a Mobile Health Screening Service

Mobile Health Screening Service

Small mobile health screening service in hospital

3 hospital staff
Corporate clients with 30-100 employees per site Paper based, Linear work flow

Business improving, staff unable to cope!

As Is Value Stream map

Registration & Health Questionnaire 5 min Wait: 5min Physical Measurements: BMI, Waist circumference, Blood pressure 5 min Blood measurements: glucose, cholesterol 5 min

Report & Counseling

Why am I waiting?

10 min

Wait: 5-15min

Wait: 5-15min

Wait: 5-20 min

Business Value Add

A study of 50 customers on site Entire work flow: 45 80 mins per customer High variability in turnaround times Bottlenecks at every step

Customer Value Add Non-value added

Problems
Uneven workload > Bottlenecks at every point Long and unpredictable wait times: 45- 80 mins (for a crowd of 50) Illegible handwriting on forms and reports - errors Inconsistent Counselling: quality of advice varies Customer complaints
Registration Health Questionnaire Physical Measurements: BMI, Waist circumference, Blood pressure Blood measurements: glucose, cholesterol Report & Counseling

Suggestions for improvement

Hire more staff! Automate entire process with an IT system! Wireless devices for measurements! Pre-register
Physical Measurements: BMI, Waist circumference, Blood pressure

Registration Health Questionnaire

Blood measurements: glucose, cholesterol

Report & Counseling

As Is Value Stream map

Registration & Health Questionnaire 5 min Wait: 5min Physical Measurements: BMI, Waist circumference, Blood pressure 5 min Blood measurements: glucose, cholesterol 5 min

Report & Counseling

Why am I waiting?

10 min

Wait: 5-15min

Wait: 5-15min

Wait: 5-20 min

Business Value Add Customer Value Add Non-value added

Eliminate / Minimise Non-value added steps (Waste) Minimise Business value-add steps Enhance Customer Value Steps

To Be Process
New Health Screening System technology as an enabler Pre-register through Online Portal. Complete Questionnaire Height, Weight, BP Questionnaire

Customer Queue Pool

iQueue manager
PULLS Blood measurement Station

Report engine

Counseling

Register on-site

Health Portal

100% improvement (pilot study)

With 3 staff
Before Process Max Load Customer Wait time Savings Manual Linear flow 12 customers/hour 45-80 mins (high variability) After Automated Pull system 24 customers/hour 20-30 mins (lower variability) $2 per customer

Other customer value-add: Health screening report engine (with algorithms) ensures consistent advice following clinical guidelines Reports uploaded to Consumer Health Portal - available 24/7. Health Portal creates Personalised Action plans with suggestions for lifestyle improvements.

Alexandra hospital (2007)

Health screening clinic (12 staff) 400% improvement Turnaround: 22 customers/hr to 95 customers/hr Wait time: 60 min to 15 min

Case study 2 Kaizen at A&E

Problem at AH A&E
The A&E is facing an increasing patient load over the years. Increasing complaints of long wait times to see Dr, and mistakes made by junior staff in peak hours.

Discharge Triage Clerking Pt Info Registration Wait for Consult Consultation Assessment Pt Info Post Consult Treatment Investigations Lab test Dressing Inpatient Admission Financial Counselling

BMU Portering

As Is Patient flow in the A&E (Value stream map)

Possible solution
Registration in parallel family member to help Bring Senior Dr forward to triage and consult Simple cases can be discharged on the spot. More serious patients, Senior Dr can direct patient to appropriate treatment more efficiently
Registration Discharge Post Consult Treatment Investigations Lab test Dressing Discharge Consultation Assessment Inpatient Admission Financial Counselling

Triage Clerking Pt Info

Consultation Assessment

Wait for Consult

Investigations
Lab test

BMU
Portering

To Be Patient flow in the A&E (Value stream map)

Real Kaizen done in AH A&E

- Bring the senior Dr forward.

Case 3: Learning from APPLE

Mac OS X 10.6 Snow Leopard
Release strategy is highly unorthodox in 2009

Cheaper upgrade cost: US$30

Faster speedy installation (15mins), boot up, opening of programs, intrinsic software runs on 64bit

Smaller - only half the size of its predecessor. Involve tightening up the screws, compressing chunks of the code and eliminating a huge stash of printer drivers. Downloads printer drivers on demand. (Pull concept)
Better refined features Microsoft Exchange compatibility, Viewable Icons Apple programmers pored through all the bits of Mac OS X, they kept stopping and fixing little things that had always bugged them, or coming up with neat little ways to make things better.
http://www.nytimes.com/2009/08/27/technology/personaltech/27pogue.html

Kaizen () in Healthcare IT
Some TPS tips for you

Step 1 Study As Is Process

Go & see for yourself the processes on the ground Identify the common business scenarios done by a mix group of Clinical, Ops, IT Staff.

Look at the 3 key flows & interactions: People, Information, Equipment/Material

Look at processes end to end in a continuous flow, avoiding silos - problems may become more visible. Measure if possible eg. time betw steps, turnaround times, error rates

Step 2 Develop To Be Process

Derive the value stream map from the current process identify wastes, bottlenecks, failure points Brainstorm to improve process: Enhance patient valueadded steps as much as possible. Reduce/remove non-value added ones. You may not be able to solve every problem. Its ok to start with small steps first. Technology may not solve your problem. Solutions may be process-related.

Step 3 Test the new process

Initial user requirements can be gathered from new process map. Build a prototype and test it with the new process flow (eg. involve select grp of staff and few patients) Repeat Step 1 & 2 again Observe, Measure, Improve Measure whatever that can be measured & review them constantly eg. how often a dr/nurse accepts your medical alerts Communicate

Step 4 Finalise Prototype & Process

If prototype and process is stable and working, finalise & document good practices into standard practice. Push into full system development.

Note: If process highly unstable (big variations & chaotic steps), DO NOT automate. Stop to fix or stabilise the process first before proceeding.

Step 5 Continuous Reflection

Monitor measure/quantify Reflect Look for improvements Communicate, communicate, communicate

How can I improve my system development process?

If possible incorporate Agile development techniques which complement TPS ideals: Active Stakeholder Participation: Multi-party Prototype teams Share Openly Be brave to accept feedback & change Iterate in Small Increments Use the Simplest Tools

Major Issue with Agile techniques: Scope creep - firm control with clear objectives needed

How to Go Lean?
Top Down Participation

Need to create a Organisational Culture

TPS is not only about applying tools or systems to each process but Developing a kaizen mindset in every employee

Patient-Centric

Bottom-up participation

Every staff must be involved

Take Home Points - 1

Healthcare processes are often complex, not streamlined > IT implementation challenging.
Applying technology over inefficient processes will often amplify underlying problems and lead to project failures. Before any system development, streamline and stabilise process first. Automate later.

Take Home Points - 2

Do not be afraid to make problems more visible.
End to End Process Flow should be done from the customer perspective (value add steps)

Continuous Reflection (Hansei / ) & Learning essential to adapt to changes.

TPS can be used wrongly, especially in silos

Questions/ Feedback?

Acknowledgements

Mrs Chew Kwee Tiang, Khoo Teck Puat Hospital

GreenFossil www.greenfossil.com iQueue (queue and workflow solutions)