CASE STUDY HELP

A Practical Guide to Applying Lean Tools and Management Principles to Health Care Improvement Projects ROSS W. SIMON, BA; ELENA G. CANACARI, RN, CNOR

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3.6

ABSTRACT

Manufacturing organizations have used Lean management principles for years to help eliminate waste, streamline processes, and cut costs. This pragmatic approach to structured problem solving can be applied to health care process improvement projects. Health care leaders can use a step-by-step approach to document processes and then identify problems and opportunities for improvement using a value stream process map. Leaders can help a team identify problems and root causes and consider additional problems associated with methods, materials, manpower, machinery, and the environment by using a cause-and-effect diagram. The team then can organize the problems identified into logical groups and prioritize the groups by impact and difficulty. Leaders must manage action items carefully to instill a sense of account- ability in those tasked to complete the work. Finally, the team leaders must ensure that a plan is in place to hold the gains. AORN J 95 (January 2012) 85-100. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.05.021

Key words: Lean thinking, Lean management principles, improvement projects, structured problem solving, facilitation techniques.

A research team headed by James Womack, PhD, at the Massachusetts Institute of Tech- nology International Motor Vehicle Pro-

gram coined the term “Lean” to describe Toyota’s business processes during the late 1980s.1 The core idea of Lean is to maximize value for customers while using fewer resources and minimizing waste.

A Lean organization focuses its key processes on

continuous improvement.

Applying Lean management principles im- proves workflow by reducing waste-related

delays, workarounds, and rework. Lean im-

provement focuses on increasing value for cus- tomers, both internal and external, across the entire value chain as viewed from the customers’

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© AORN, Inc, 2012 January 2012 Vol 95 No 1 ● AORN Journal 85

perspective. Value is enhanced by eliminating waste (ie, any activity that does not add value) in the process; thus, quality, cost, and timeliness of delivered services can be improved and time made available to focus efforts on true value- added activities.

Patients are key external customers to health care organizations. The patient’s value chain begins when the patient enters the surgeon’s office. Internal customers are also important in the process. For example, the OR is an internal customer of the central processing department (CPD) because the CPD is an internal supplier of instruments, supplies, and equipment to the OR. Conversely, the OR is an internal supplier to the CPD when the OR returns bioburden- laden instruments coated with an enzymatic spray to facilitate cleaning. Therefore, depart- ments can be both internal customers and sup- pliers. Truly Lean organizations strive to supply all customers, both external and internal, with exceptional service.

The core values of Lean management theory include

� respect for people (eg, patients, staff members, managers, physicians),

� continuous improvement (eg, easier, better, faster, cheaper), and

� human development.2

For the Lean approach to work, leaders must create a favorable environment in which prob- lems are recognized as opportunities for im- provement. People are not problems, they are problem solvers, and emphasis is placed on finding solutions to problems rather than as- signing blame.

Lean principles help perioperative leaders improve processes with a set of management techniques that define how they can identify and reduce waste. A Lean project we called Going to Gemba with the Hip Breakdown Team was conducted at Beth Israel Deaconess Medi- cal Center, Boston, Massachusetts, from Janu-

ary 2009 to July 2010. Gemba is a Japanese word meaning workplace or where the work occurs. Direct observation of the work where it occurs is a key element of Lean problem solv- ing and process improvement. We had the op- portunity to improve the OR breakdown process for hip procedures. Inappropriate breakdown procedures were resulting in increased costs, and we realized that we could potentially im- prove patient, surgeon, and staff satisfaction by addressing such problems as

� lost instrumentation, � improperly cleaned instruments, � ineffective use of resources, � work arounds (eg, immediate-use sterilization), � sharps hazards, and � holes in wrappers.

In this article, we provide the steps for conduct- ing a Lean process improvement project, from defining a project through maintaining the gains achieved. Facilitation tools and techniques are provided to help ensure that improvement team meetings are focused and productive.

APPLYING LEAN MANAGEMENT TO HEALTH CARE Lean management theory has a long history of success in manufacturing. The same Lean princi- ples and tools that are applied in manufacturing plants are directly applicable to the health care setting. The root cause for failures is often the same for manufacturing and health care— breakdowns in communication and misunder- standing the needs of customers.

In reviewing the literature in preparation for our project, we found many articles on using Lean management techniques in health care that gave general descriptions of Lean theories and tools but provided little explanation of how they are applied and at what phase of the improvement project. Few articles described a practical ap- proach for solving complex problems, especially in opportunities that require an interdisciplinary effort. Jargon is often used in these articles, most

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commonly Japanese production-line terms such as jidoka (ie, the ability to stop production lines in the event of problems such as equipment mal- function or quality issues), poka-yoke (ie, mistake proofing), and hoshin kanri (ie, a strategic plan- ning process), which adds a layer of confusion rather than enhancing understanding. In our proj- ect, we limited the use of Japanese terms (eg, Gemba, kaizen) to minimize confusion, although we did not eliminate them completely.

Dr W. Edwards Deming provided a foundation for Lean management theory in his “14 Points” pub- lished in his book Out of the Crisis in 1982.3 The points that are most applicable to health care include

� leading the organization (ie, not just supervis- ing people),

� driving out fear, � breaking down barriers between departments,

and � transforming the organization, which is every-

one’s job, not just that of managers.

Lean theory is rooted in the scientific method and the Plan-Do-Check-Act (PDCA) cycle,4 originally developed by Walter A. Shewhart, a Bell Labora- tories scientist who was Deming’s friend and mentor. The PDCA cycle is a four-step model for carrying out change:

� Plan—recognize an opportunity, plan a change, and estimate the impact of the planned change.

� Do—test the change; carry out a small-scale study.

� Check—review the test results and identify what you have learned.

� Act—take action based on what is learned in the study; if the change did not work, repeat the cycle with a different plan; if the change is successful, incorporate what is learned from the test into the work process used in the area.

The PDCA cycle is repeated over and over to continuously improve a process.

Lean thinking helps define both what has to be done to solve a problem and how work is per-

formed. Lean approaches help managers recog-

nize and reduce the waste in processes. Wastes

are activities that add no value from a customer

perspective, including

� Waiting—waiting for the next event to occur

or next work activity

� Motion— unnecessary movement by employ-

ees in the system

� Transportation— unnecessary movement of the

product in a system (patient, specimens,

materials)

� Defects—time spent doing something incor-

rectly, inspecting for errors, or correcting

errors

� Overprocessing— doing work that is not val-

ued by the customer or caused by definitions

of quality that are not aligned with patient

needs

� Overproduction— doing more than what is

needed by the customer or doing it sooner

than needed.5

Understanding waste is critical to improvement

because wastes add cost but add no value; they

are typically viewed to be “part of the way we

work here.” Building awareness in team mem-

bers that much of their routine work is actually

“waste” from a customer perspective can be

motivating, because wasteful activities are often

activities staff members already struggle with

every day but rarely have the ability to change.

Reducing waste in a process increases the ca-

pacity to do more value-adding work, such as

providing patient care.

When drafting the project charter, henceforth re-

ferred to as the scope statement, involving individu-

als who have knowledge of the problem or opportu-

nity and also have a stake in its solution helps

ensure that there is a clear understanding of all as-

pects of the issue. These individuals also can add

suggested approaches to the scope statement, which

can help the team get off to a brisk and success-

ful start rather than wasting time at the first few

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meetings identifying what the first steps of the proj-

ect should be.

Getting the right team members involved is critical to success. Department managers involved with drafting the scope statement can quickly identify those who have the knowledge and expe- rience necessary to solve the problem. Gaining approval from supervisors to permit their staff members to serve on the team is facilitated by having managers participate in developing the scope statement.

After brainstorming to identify all problems and possible solutions, the improvement team implements corrective actions and responds ac- cording to the results. As defined in the PDCA cycle, the results attained after corrective ac- tions are implemented may not be what were originally anticipated. “Checking” the results often leads to additional corrective actions to achieve desired outcomes. Lean theory is fo- cused on achieving process perfection over time, not necessarily on the first attempt. Lean improvements are intended to make a process better but not perfect. There is nothing wrong with an initial failed attempt as long as team members learn from their failures and adjust accordingly.

Very few problems exist that are too com- plex for a team of the right individuals to solve when the team uses structured problem-solving techniques and has strong management support. Lean is not “another job” to be performed in addition to normal work; it is the way people work. Lean is about making the right work eas- ier to do. Deciding when to use Lean principles and tools is not always easy, however, and there is no one approach to solving all problems.

THE IMPROVEMENT TEAM PROCESS Every team needs a sponsor, a leader, and a facilitator. If the team encounters roadblocks that prevent progress, the sponsor is responsible for removing those roadblocks. The sponsor is

the go-to person if the team cannot move forward.

The team leader is responsible for keeping the team focused and productive and ultimately is responsible for the success of the project. If addi- tional resources are needed, the leader obtains them. If team members do not volunteer to com- plete tasks, the leader assigns the work. The leader is also responsible for reporting progress to those charged with managing and supporting the Lean process in the organization. The leader is focused on strategy and resources and deals with questions such as

� What should the team do next? � Who can help us with this part of the project?

The facilitator is concerned with how the team works and ensuring that progress is made at each team meeting. Using the right tool or technique at the right time is part of the facilitator’s responsi- bility. Table 1 describes some key facilitation techniques that help improvement teams stay fo- cused and productive.

A dictatorial leader can deflate morale so that members want to abandon the project; a good leader energizes the team. Likewise, the team can flounder when the facilitator does not arm team members with the right tool at the appropriate time. The leader and facilitator work as a team sharing in strategic planning from one meeting to the next. For example, on the Surgical Hip Kit Breakdown Process Team, the leader and facilita- tor met before one meeting and developed a plan to ask the team whether every instrument in a pan of instruments was needed. The team subse- quently decided to create a subteam to review the contents of the instrument pans (ie, hip kits). The subteam ultimately removed 14 lb of unnecessary instruments from a hip kit. By doing so, we re- duced an ergonomic hazard and decreased unnec- essary work and related expenses in the CPD and the OR.

Having a standard problem-solving process is essential. This process includes eight steps:

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1. defining the scope statement, 2. identifying the current process and associated

problems using a value stream process map, 3. transferring the identified problems to a

cause-and-effect diagram, 4. organizing the problems into logical group-

ings in an affinity diagram,

5. prioritizing problems in an impact difficulty grid,

6. managing action items with an activity scorecard,

7. monitoring progress of key action items dur- ing implementation, and

8. putting a plan in place to hold the gains and spread the learning after project goals have been accomplished and the team has been disbanded.

Scope Statement Any project can fail if the goal is not clearly defined, understood, and accepted. Step 1 of the improvement process requires that the manage- ment team clearly define the details of the proj- ect with measurable and challenging yet achiev- able goals. A scope statement (Figure 1) that contains a clear definition of the problem to be solved and the measureable goals to be achieved is essential. Whenever possible, the voice of the patient should be an element of the project. The way in which this document is drafted can strongly influence the success or failure of a team’s project. The scope statement should not be developed by one individual. This could be considered “cubical engineer- ing”— one person attempts to define and re- solve a problem in isolation with no input from the people involved. The scope statement should be drafted by those who

� have key knowledge of the problem/ opportunity,

� are supervisors or department managers of the likely project team members, and

� have a stake in solving the problem.

Key elements of the scope statement include the following:

� background justification; � quantifiable goals; � a target completion date; � suggested approach; � membership including the sponsor, leader,

facilitator, core members who are expected

TABLE 1. Facilitation Techniques

Prepare for the meeting Arrive to the team meeting room early—set it up so that

when participants enter the room the team is ready to proceed, because nothing is more precious than time.

Make the topic being discussed visible in words � Sit close to a flip chart and use the chart to make key

elements of the discussion visible and understandable to all team members.

� When the need for action surfaces and there is a threat that the needed action might not be clear to everyone, write the action on the flip chart and ask “Is this correct?”

� Use the same technique when adding any information to the activity scorecard. The flip chart marker is a powerful instrument; when the facilitator writes on the flip chart, team members become engaged and galvanized.

Ask questions Use the Socratic technique—do not tell, ask: � Would it make sense for us to . . .? � Should we consider . . .? Use flow diagrams Make processes under discussion visible as flow diagrams. Define area layouts clearly When discussing the physical layout of an area, use the flip

chart and draw it out. Hand waving is not a good method of describing the physical characteristics of a layout.

Use meeting time wisely � Encourage completion of action items outside the

meeting. � Use meeting time strategically by reviewing the status

of action items and planning the next step. Some activities, such as brainstorming and prioritizing, require full team participation during a meeting; most others do not.

� Form subteams for activities requiring participation of multiple team members.

Prevent sidebar discussions When someone talks, everyone listens; discourage sidebar

discussions during meetings.

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Figure 1. An example of a scope statement—a document that management team members (ie, those with key knowledge of the problem or opportunity) and the supervisors of likely team members create before the project is launched to provide justification for the project, goals to be accomplished, a target completion date, metrics, team membership, and simplified process flow.

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to attend every team meeting, extended

members who are brought onto the team as

needed; and

� macro-flow, which is a simplified, process-

flow diagram of the current state, typically

consisting of about six steps.6

The macro-flow provides an overview of the

process on which the team will be working.

This overview is particularly helpful for those

who do not have a deep knowledge of the pro-

cess needing improvement. Although we did

not include a macro-flow in the scope statement

for this particular project, typically it is a stan-

dard element of a scope statement.

Lean improvement projects are not just per-

formed by a select few “champions” in the orga-

nization, but rather by those who do the work

every day. For example, members of the team

to reduce turnaround time between total hip

replacements at Beth Israel Deaconess Medical

Center included

� anesthetists;

� a perioperative associate chief nurse;

� attendants (ie, orderlies who assist with OR

turnover);

� the CPD second-shift supervisor;

� CPD technicians,

� the OR clinical advisor (ie, a service line

leader or coordinator who has oversight for

the day-to-day operations of specific service

lines);

� the clinical manager of scheduling

operations;

� clinical nurses from the OR, preoperative

holding area, and postanesthesia care unit;

� a management engineer who guides the team

to use Lean thinking and structured problem-

solving tools;

� an OR educator;

� the perioperative project director;

� surgeons; and

� a surgical technologist.

Value Stream Process Map Step 2 requires that improvement team members prepare a detailed, process-flow diagram. Team members must come to agreement in identifying and then becoming familiar with all steps in the process (Figure 2). There were a total of 66 pro- cess steps in the value stream process map for our project. The first step begins with “Patient sees his/her doctor” and the last step is “Anesthesia technologist places the suction liner into canister on wall, leaves the OR, and washes hands.” While listing each process step, the leader posts problems and opportunities for improvement next to the associated steps. The following are exam- ples of a problem and an opportunity for im- provement we identified while listing process steps.

� Process step #32: Central processing depart- ment personnel pick instruments and dispos- able supplies one day before the scheduled procedure. � Problem: Loaner instrument and supply

kits are not always sterile and ready to use. � Process step #52: Anesthesia professional and

circulating nurse wheel the patient out of the OR. � Opportunity for improvement: Call atten-

dant in sooner to assist with patient trans- fer and to be available for turnover.

Cause-and-Effect Diagram During step 3, improvement team members trans- fer all problems identified while preparing the value stream process map to a cause-and-effect diagram template to help identify the root causes of the problems (Figure 3). The question posed on the cause-and-effect diagram is “What are the issues or root causes that contribute to the prob- lem being solved or the opportunity for improve- ment?” Team members place each problem next to the appropriate rib. Standard categories include

� methods, � materials, � manpower,

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32. CPD personnel pick instruments and disposable supplies approximately 1 day before the scheduled procedure.

33. Postanesthesia care unit (PACU) clinical advisor writes the time when beds are needed for the entire day for all patients and all ORs.

35. PACU orderly checks with resource nurse or unit coor- dinator to find out which rooms patients will go into and takes beds to the assigned ORs for each patient.

34. Holding area nurse checks all paperwork for accuracy, availability, and completeness.

36. Anesthesia professional completes the preoperative form and the anesthesia consent form.

37. Anesthesia professional places IV and other invasive lines.

38. Anesthesia professional performs pain block (50% of patients receive a pain block for postopera- tive pain control); femoral blocks are just for knees.

Loaner instrument and

supply kits are not always sterile and

ready to use.

If there is not an attendant in the holding area, the PACU clinical advisor could send an OR attendant

to get the bed or call the central transport depart-

ment to get the bed. Possible delay depending

on whether the atten- dant can take the bed

out of the room after the previous patient has been discharged or whether an additional bed should be obtained from the base-

ment but sometimes there is not a bed available in

the basement.

If the informed surgical consent

form is not complete, the holding area nurse

may be delayed in preparing the patient,

which also slows down the anesthesia professional in his or

her preparation of the patient.

Interpreter services are not always avail- able when needed

because they had not been notified of the need or they didn’t arrive early enough.

Biggest delay:

lack of bed availability

affects everything downstream.

Figure 2. An excerpt from a value stream process map—a few key steps of the much larger, comprehensive process-flow diagram. Note problems (ie, shaded annotations) that team members identified while creating the value stream process map.

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39. Anesthesia professional in holding area waits for room readiness.

40. Anesthesia professional transports the patient from the holding area to the OR.

42. Anesthesia professional pre- pares equipment for the procedure.

41. On the day of surgery, circulating nurse checks all of the equipment on the 1st time primary hip procedure cart—typi- cally, no problems are encountered with pri- mary hip procedures; problems are usually confined to revision hip procedures.

43. Circulating nurse and surgical tech- nologist prepare the room for the proce- dure and ensure that there are not any roadblocks.

44. Surgeon closes the incision.

45. Scrub person puts the instruments back into the pans.

S U R G E RY IS P E R F O R M E D

Instrument availability can be affected if booking information is not

communicated to the OR clinical advisor; resources may not

be keeping up with demand.

The check box

signifies that all equipment is

available for the procedure. It is not a room readiness checkbox. When the timing of the check is delayed,

patient flow is interrupted.

Induction

of anesthesia complete; surgeon should be present but sometimes is not, so circulating nurse must page to locate surgeon,

which causes a delay.

PACU workflow for provid- ing beds and oxygen

holders and cylinders is not always coordinated with OR needs, which

can cause a delay.

Figure 2. Continued

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� machinery, and � the environment.7

Team members can add ribs with different names, if appropriate. Then team members stand back and ask, “What problems did we miss listing when we created the value stream process map?” Normally, team members identify additional prob- lems, some of which may be very significant. The next step is to amend the value stream process map. For instance, in our project, after we trans- ferred the problems to the cause-and-effect dia- gram we identified the problem of bed availability or, specifically, the lack thereof.

Affinity Diagram Step 4 involves organizing the problems into logical groupings in an affinity diagram (Figure 4). This

� reduces the number of problems to manage- able groups and helps define root causes;

� eliminates redundancy in problems identified during the preparation of the value stream process map;

� ensures that solutions developed will address a broad scope of related problems; and

� helps identify a few strategic themes for prob- lem resolution so the team is not trying to address many individual problems or symp- toms. The themes in our project included the following: � instruments availability, � attendant availability, � holding area size, � scheduling mishaps, � machinery availability and function, and � other (eg, delay in a patient emerging

from anesthesia can delay room

breakdown).

Impact Difficulty Grid During step 5, team members prioritize problems based on

� the impact that solving the problem group will have on meeting the team goals and

� the difficulty of implementing solutions to re- solve the problem group (Figure 5).

The outcome of this step helps the team decide which group of problems should be addressed initially to achieve the greatest improvement with minimal effort. In our project, the impact/

If there is not an attendant in the holding area, the post-

anesthesia care unit clinical advisor should call the OR

resource nurse to determine if the OR or the transport team

should provide the bed.

Lack of case pick location (ie, a specific location

[eg, shelf] where supplies are stored) in the central

processing department and in the OR can cause delay.

Holding area A is undersized.

Sometimes the need for intraoperative x-rays and autotransfusion are not added

to the OR schedule, which may require a workaround to ensure availability at the

right time; if the clinical advisor does not add this information to the OR schedule,

it may be missed and could cause services to not be available when needed.

One day before surgery, orthopedic of- fice personnel confirm that the surgical

procedure is scheduled. Sometimes the patient refuses surgery, which causes

a gap in the schedule; this results in a change to the block schedule, so the

preoperative nurse calls and asks the patient to arrive early, which is stressful

for the patient.

Manpower

Environment Materials Machinery

Methods

What causes delays in room breakdown?

Figure 3. A cause-and-effect diagram in which the problems identified in the value stream process map are grouped into categories, such as methods, materials, machinery, manpower, and the environment. This is a simplified diagram in which only one problem is shown for each rib; in reality, multiple problems were identified for all but one rib.

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difficulty analysis indicated that we should start developing solutions for issues related to instru- ments to make rapid and meaningful progress toward meeting the team’s goals. Resolution of instrument problems was achieved quickly with minimal effort. Early wins help maintain a high level of energy and team morale. Another prob-

lem, reviewing and updating preference lists, also was solved quickly, which helped keep the team motivated. Maintaining enthusiasm for the project is necessary because complex projects may require several months to complete.

Activity Scorecard Step 6 involves managing action items by clearly defining all corrective actions using the activity scorecard (Figure 6). This scorecard is updated at each weekly team meeting. Key elements of each line item include the

� task name, � issue addressed, � next activity, � priority relative to other action items (ie,

everything cannot be “high”), � responsible individual, � target completion date, and � current status.

This tool drives progress at each team meeting. The leader ensures that the matrix is visible to the team members by using a document camera or overhead projector when adding or updating action items. Doing so helps avoid confusion when defining the planned work. Making this “contract” visible during

Instruments: Loaner Policy

Loaner instruments not received on time—need loaner instrument guideline.

Attendant: Possible Delay in Bed Availability Postoperatively

Possible delay depend- ing on whether an attendant can take the bed out of the room af- ter the previous patient has been discharged or whether an additional bed should be obtained from the basement; however, sometimes there is not a bed avail- able in the basement.

Holding Area: Surgeon Availability

Induction of anesthesia is complete; surgeon should be present but sometimes is not, which causes a delay because the circulating nurse must page to surgeon to return to the OR.

Scheduling: Consent Form

If the informed surgi- cal consent form is not complete, the surgeon may need to break scrub at the beginning of the day or in between procedures, which slows down nurses in the holding area and the OR and slows down the anesthesia professional.

Other: Waking Patients

Patient requires additional time for awakening and extubation so personnel cannot begin to break down the OR to prepare for the next procedure.

Figure 4. An affinity diagram in which grouping seemingly disparate problems into logical groups helps the team manage the many problems and opportunities for improvement identified and develop corrective actions. This is a simplified diagram in which only one problem/opportunity for improvement is shown for each category; in reality, there were multiple problems in each category.

High X

Attendants

X Holding

Area

X Instruments

Impact

Low

High Difficulty Low

X Central

Processing Department

Dirty

Elevator

Figure 5. An impact difficulty grid used to prioritize the groups of problems identified in the affinity diagram according to the impact on goal attainment and difficulty to solve.

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team meetings instills a sense of accountability for those tasked with completing work. This sets the tone to ensure that work happens.

Implementation Plan Step 7 is the implementation plan for corrective

actions to resolve the identified problems (Figure

7). This tool serves as a timeline for key action

items. It provides a high-level view of key tasks

and also aids in creating a sense of accountability

by highlighting sluggish response to planned

work. For example, a key task in our implementa-

tion plan was the need to develop and implement

a loaner instrument policy.

Holding the Gains and Spreading the Learning A key step when nearing completion of any im- provement project is planning actions that will sustain the gains that the team has achieved. All

too often, realized improvements are lost when the project closes and team members are dis- banded because no plan was put in place to em- bed the improvements in the way work is performed.

Key metrics should be established as part of the project, and someone or a group should be assigned to regularly review the metrics. That way action can be taken when the improve- ments slip outside the desired parameters. Turn- over time was the most important key metric for our project. Performing regular audits sets the stage for entrenching the improvement. It might be necessary to augment the existing re- sponsibilities of an individual or create new ones to maintain the achieved gains. When new employees join the organization, they should receive training on the new and improved pro- cess. Updating position descriptions, policies,

ID TITLE ISSUE(S) NEXT ACTIVITY Priority Who TARGET

COMPLETION DATE

STATUS

1

Sharps data

To address sharps goal: Develop a process to manage sharps.

Remind attendants not to take tables without red tracking sheets.

Medium OR nurse manager

7/26/10

Brought “helpful hints regarding sharps” to OR practice council and developed process for ensuring that tables do not leave OR with sharps. Ordered extra long,extra large stringers. Regarding “Follow up on 19 blades sent from podiatry clinic to central processing department (CPD) week ending 6/4,” project director spoke with podiatry clinic personnel about turnover. OR nurse manager is now being paged when sharps come to CPD. Attendants have been instructed to not take tables out of the OR that are not identified with a red tag.

2

Loaner policy

Obtaining loaner equipment and supplies affects set-up times so need to develop a loaner policy for contractors that defines expectations. Without control of loaner items, a domino effect can occur in CPD. Having a workable, enforceable policy will help relieve pressure on CPD.

Work with the senior materials management specialist to ensure complete labeling of loaner kits.

Medium

Project director,

perioperative services

7/26/10

Currently using a scale to monitor weight of loaner kits. Escalation (ie, speaking to the person who has the next higher rank) in order to get the work done when loaner kits are delivered late. Total knee kits are not labeled clearly.

3

Auditing

Need to develop an audit form and schedule to check the effectiveness of systems (eg, kit tracking). Need to develop and implement a plan to ensure that the corrective actions will stay in place after team is disbanded.

Present and discuss questions and answers at the quality improvement council and then at the OR practice council.

Medium

Associate chief nurse,

perioperative services and RN clinical

advisor

7/26/10

Towels will be included in metrics. Quality improvement sheet has been designed.

4

Physician- specific instrumentation

Non-standardized physician specialty instrumentation requires increased storage space and can contribute to losing instrumentation.

Update count sheets after surgeons’ instruments are added to basic kits.

Medium

OR clinical advisor

and core technologist

7/26/10

Succeeded in getting doctors to use curettes with black handles.

Attending 6/21/10 Meeting:

Updates in BLUE

Figure 6. An activity scorecard, which helps the team manage the myriad corrective actions required to resolve the problem.

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and standard operating procedures helps ensure that the improvements live on, as will making supervisors responsible for maintaining and im- proving these processes.

KAIZEN EVENTS Many people equate Lean implementation with rapid-movement kaizen events, which typically are two to three all-day meetings to make rapid progress on one or more tasks.8 In our project, a kaizen event might have been used for reviewing and modifying preference lists, which did not necessarily show where to find supplies in the OR. Time was often wasted searching for sup- plies, especially for someone filling in for a regular employee.

For this project, the team needed to review

the content of preference lists, update them as

necessary, and add storage locations. However,

using a kaizen event for this and other tasks

would have required that employees be pulled

away from their normal job functions for an

extended period of time, which management

leaders did not approve. Therefore, the team

selected a mixed approach in which team mem-

bers met in small subgroups between the regu-

lar weekly team meetings to accomplish tasks.

Updating the preference lists took several

weeks to complete. Team members used the

regular weekly team meetings as strategy ses-

sions to check on the progress of tasks and de-

cide the next steps. Team members were more

comfortable with this model of making steady

progress over the course of the project rather

than holding kaizen rapid-improvement events.

CONCLUSION

Many process improvement projects in a health care setting can benefit from the structured Lean approach, which has been successfully applied to many other Beth Israel Deaconess Medical Center

Value stream process map

Cause and effect diagram

Revised and updated preference lists

Hire open attendant position

Central processing depart- ment location/preference lists

OR location to preference lists

Standardize table breakdown and training

Validate loaner kits

Update vendor count sheet

Develop loaner policy

Establish attendant system

Purchase additional drills and establish preventive

maintenance program

Reduce kit content

Standardize physician- specific instrumentation

Audit case carts

Hire the new position of senior material management

specialist

Transfer knowledge to other procedures

Oct 26 Nov 2 Nov 9 Nov 16 Nov 23 Dec 7 Dec 14 Dec 21 Dec 28 Jan 4 Jan 11 Jan 18 Jan 25

Complete

Complete

Complete

Re-label shelves

Practice Council recommends creating separate guidelines for the breakdown and set-up processes

Complete

Complete

Approved as-is on 1/13 by Practice Council

Observing Attendants - show the walking path taken by an individual

Complete

50% of carts are complete

Complete

Figure 7. An implementation plan, shown as an in-process document and not in its final form, lists key action items with a timeline for completion.

LEAN MANAGEMENT TOOLS AND PRINCIPLES www.aornjournal.org

AORN Journal 97

projects. Positive results from our project in- cluded the following:

� A standardized hip procedure breakdown pro- cess was developed and implemented.

� Room turnover time was decreased by 10 minutes.

� A process for safely managing sharps was de- veloped and implemented.

� All hip preference lists and pick tickets were updated.

� The basic hip kit was standardized and its weight was reduced by 14 lb.

� A loaner instrument policy was developed and implemented.

� The role to manage loaner instrumentation was developed and implemented.

� One-piece flow in assembly of kits in the CPD was developed and implemented.

� The number of surgeon-specific kits was reduced.

� The use of an enzymatic cleaning solution

to pretreat contaminated instrumentation was

implemented throughout the hospital.

� A red-tag tracking process for kits sent to the

CPD was implemented.

We also learned valuable lessons, such as

having all involved disciplines and key stake-

holders participate in the project. This allowed

everyone to gain an understanding and an ap-

preciation of each other’s role in caring for this

patient population. It also gave everyone an

understanding of Lean management in action.

In addition, when you bring together the people

who do the work and arm them with a struc-

tured problem-solving methodology, there is no

limit to what they can accomplish.

The Lean approach is simple and straightfor- ward. Using cross-functional teams guided by Lean principles and tools to solve complex prob- lems in a health care setting allowed employees, patients, and the organization all to benefit. Em- ployees, who for years have tried unsuccessfully to influence positive change through the manager/

employee relationship, now have the opportunity to offer their thoughts and good suggestions in an open, friendly, and structured environment where their input is valued and acted upon. The organi- zation benefits by tapping into a rich reservoir of talent and experience to solve its most challeng- ing problems.

References 1. What is Lean? Lean Enterprise Institute. http://www

.lean.org/whatslean/. Accessed October 19, 2011. 2. Exploring the “Respect for People” principle of the

Toyota way. http://www.gembapantarei.com/2008/02/ exploring_the_respect_for_people_principle_of_the.html. Accessed October 13, 2011.

3. Deming WE. Out of the Crisis: Quality, Productivity, and Competitive Position. Cambridge, MA: Cambridge University Press; 1982.

4. Project planning and implementing tools: plan-do-check- act cycle. American Society for Quality. http://asq.org/ learn-about-quality/project-planning-tools/overview/ pdca-cycle.html. Accessed September 11, 2011.

5. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. Boca Raton, FL: CRC Press; 2009:43.

6. Flowchart tutorials: flowchart definitions and objectives. Edraw Soft. http://www.edrawsoft.com/Flowchart-tutorial .php. Accessed October 14, 2011.

7. Brassard M, Ritter D. The Memory Jogger. Salem, NH: GOAL/QPC, Inc; 1994.

8. The New Lean Pocket Guide: Tools for Elimination of Waste. Chelsea, MI: MCS Media; 2007:37.

Resources Brassard M. The Memory Jogger. Salem, NH: GOAL/QPC,

Inc; 1989. Brassard M, Ritter D. The Memory Jogger. Salem, NH:

GOAL/QPC, Inc; 1994. Butman J. Flying Fox: A Business Adventure in Teams and

Teamwork. New York, NY: AMACOM; 1994. Byham WC, Cox J. Zapp! The Lightning of Empowerment.

New York, NY: Harmony Books; 1988. Deming WE. Out of Crisis. Cambridge, MA: MIT Press;

2000. Dennis P. Getting the Right Things Done. Cambridge, MA:

Lean Enterprise Institute, Inc; 2006. Drew J, McCallom B, Roggenhofer S. Journey to Lean,

Making Operational Change Work. New York, NY: Palgrave Macmillan; 2004.

Fetteroll EC, Hoffherr GD, Moran JW. Growing Teams: A Down to Earth Approach. Salem, NH: GOAL/QPC, Inc; 1993.

Fogg CD. Team-Based Strategic Planning: A Complete Guide to Structuring, Facilitating, and Implementing the Process. Seattle, WA: CreateSpace; 1994.

Imai M. Kaizen: The Key to Japan’s Competitive Success. Columbus, OH: McGraw Hill; 1986.

LEAN MANAGEMENT TOOLS AND PRINCIPLES www.aornjournal.org

AORN Journal 99

Isachsen O, Berens LV. Working Together: A Personality- Centered Approach to Management. Lausanne, Switzer- land: Institute of Management Development; 1988.

Katzenbach JR. Teams at the Top—Unleashing the Potential of Both Teams and Individual Leaders. Boston, MA: Harvard Business Publishing; 1998.

Katzenbach JR, Smith DK. The Discipline of Teams. Hobo- ken, NJ: Wiley; 2001.

Kobayashi I. 20 Keys to Workplace Improvement. London, England: Productivity Press; 1990.

Madison D. Process Mapping, Process Improvement, and Process Management—A Practical Guide to Enhancing Work and Information Flow. Chico, CA: Paton Press; 2005.

Scholtes PR. The Team Handbook. Emeryville, CA: Joiner Associates, Inc; 1988.

Spear S. Chasing the Rabbit—How Market Leaders Out- distance the Competition and How Great Companies Can Catch Up and Win. Columbus, OH: McGraw Hill; 2009.

Stratton DA. An Approach to Quality Improvement that Works. 2nd ed. Milwaukee, WI: ASQC Quality Press; 1991.

Ross W. Simon, BA, is a senior management engineer at Beth Israel Deaconess Medical Center, Boston, MA. Mr Simon has no de- clared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Elena G. Canacari, RN, CNOR, is an associ- ate chief nurse of perioperative services at Beth Israel Deaconess Medical Center, Boston, MA. Ms Canacari has no declared affiliation that could be perceived as posing a potential con- flict of interest in the publication of this article.

January 2012 Vol 95 No 1 SIMON—CANACARI

100 AORN Journal

CONTINUING EDUCATION PROGRAM

3.6 www.aorn.org/CEA Practical Guide to Applying Lean

Tools and Management Principles to Health Care Improvement Projects

PURPOSE/GOAL

To educate perioperative nurses about how to apply principles of Lean management to health care improvement projects.

OBJECTIVES

1. Describe how Lean improvement focuses on understanding the customer. 2. Discuss how Lean management principles can be applied to health care. 3. Explain how Lean management principles are used to improve quality. 4. Differentiate between the Lean management leadership roles in a quality im-

provement project. 5. Identify key Lean management tools.

The Examination and Learner Evaluation are printed here for your conve- nience. To receive continuing education credit, you must complete the Exami- nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Direct observation of the work where it occurs, which is a key element of Lean problem solving and process improvement, is described by the Japanese term a. kaizen. b. jidoka. c. gemba. d. hoshin kanri.

2. The root cause for failures, including breakdowns in communication and misunderstanding the needs of customers, are often the same for manu- facturing and health care. a. true b. false

3. Wastes are activities that add no value from a customer perspective; these include

1. time spent inspecting for and correcting defects.

2. unnecessary movement by employees. 3. overprocessing and overproduction. 4. unnecessary transportation of equipment or

supplies. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

4. Involving individuals who have knowledge of the problem when drafting the project charter or scope statement 1. helps ensure that there is a clear understanding

of all aspects of the issue. 2. helps in identifying the first steps of the

project.

EXAMINATION

© AORN, Inc, 2012 January 2012 Vol 95 No 1 ● AORN Journal 101

3. is advantageous because they have a stake in its solution. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

5. Lean theory is focused on achieving process per- fection immediately after implementation. a. true b. false

6. The _______________ is concerned with how the team works and ensuring that progress is made at each team meeting. a. facilitator b. project manager c. sponsor d. team leader

7. A scope statement 1. clearly defines the details of the project. 2. contains a clear definition of the problem to be

solved. 3. identifies measurable goals. 4. includes the voice of the patient if possible. 5. is developed by one individual from the man-

agement team. a. 1 and 2 b. 2, 3, and 5

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

8. Organizing the identified problems into logical groupings is done using a/an a. scope statement. b. impact difficulty grid. c. affinity diagram. d. cause-and-effect diagram.

9. Managing action items by clearly defining all cor- rective actions is done with the use of a/an a. implementation plan. b. activity scorecard. c. value stream process map. d. impact difficulty grid.

10. Rapid-movement kaizen events 1. are two to three all-day meetings to make

rapid progress on one or more tasks. 2. require that employees be pulled away from

their normal job functions for a period of time. 3. are accomplished using small subgroups that

meet between the regular weekly team meet- ings to accomplish tasks. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3

The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,

with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no de-

clared affiliations that could be perceived as potential conflicts of interest in the publication of this article.

January 2012 Vol 95 No 1 CE EXAMINATION

102 AORN Journal

CONTINUING EDUCATION PROGRAM

3.6 www.aorn.org/CEA Practical Guide to Applying Lean

Tools and Management Principles to Health Care Improvement Projects

T his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this continuing education program achieved?

1. Describe how Lean improvement focuses on under- standing the customer. Low 1. 2. 3. 4. 5. High

2. Discuss how Lean management principles can be applied to health care. Low 1. 2. 3. 4. 5. High

3. Explain how Lean management principles are used to improve quality. Low 1. 2. 3. 4. 5. High

4. Differentiate between the Lean management leader- ship roles in a quality improvement project. Low 1. 2. 3. 4. 5. High

5. Identify key Lean management tools. Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your knowl- edge of the subject matter? Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of read- ing this article? (If yes, answer question #9A. If no, answer question #9B.)

9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding

why change is needed. 2. I will work with management to change/imple-

ment a policy and procedure. 3. I will plan an informational meeting with phy-

sicians to seek their input and acceptance of the need for change.

4. I will implement change and evaluate the ef- fect of the change at regular intervals until the change is incorporated as best practice.

5. Other: __________________________

9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my

practice. 2. I do not have enough time to teach others

about the purpose of the needed change. 3. I do not have management support to make a

change. 4. Other: _______________________

10. Our accrediting body requires that we verify the time you needed to complete the 3.6 continuing education contact hour (216-minute) program: _

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #12502; Session: #0001; Fee: Members $18, Nonmembers $36

The deadline for this program is January 31, 2015.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION

© AORN, Inc, 2012 January 2012 Vol 95 No 1 ● AORN Journal 103

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