VlLean

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C15: Think and Learn Lean

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C15:Think and LearnLean:

Implications for an

ICU

2

When Problems are

Chronic or Reoccurring:

Find New Ways of

Thinking of Solutions

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What Can We

Learn From

Toyota?

4

But Health Care

Is Different FromManufacturing

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Toyotas Notion of Ideal

Are Defect Free

Can Be Delivered One Request At a Time

Can Be Supplied In The Version Requested

Can Be Delivered Immediately

Can Be Produced Without Waste

Can Be Produced In a Safe Work Environment

Goods and Services:

6

The IDEAL Health Care System

One in Which Patients Receive:

Correct therapy for the patient, safely & void of

complications (safe & defect free) (effective)

Appropriate therapy delivered upon request every

time (individualized) (patient focused)

Only therapy that is wanted and needed (as requested)

(equitable)

Delivered immediately (timely)

Therapy given efficiently & without waste at the

lowest possible cost (efficient)

Delivered in a safe working environment (safe)

Blue - the six goals from Crossing the Quality Chasm

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Toyotas Success

Is Not in the Tools,

It Is in the Culture

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The Toyota Paradox

Activities, Connections and

Production Flows Are Rigidly

Scripted

Yet

The Operations Are Enormously

Flexible and Adaptable.

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What Are Some of the Principles

that Drive Toyotas Success?

Standardization of Processes - eliminatevariation on processes in order to identify problems andmeasure effects of change (Rule in Use #1)

Communication - person to person and withoutambiguity (Rule in Use #2)

Elimination of Waste - use only what you need butmake sure everything you need is there (Rule in Use #3)

Improvement - constantly look for and find ways to

improve. Improvement methods should be scientificallysound. (Rule in Use #4)

10

1st Rule In Use

How People Work

All Work Shall Be Highly

Specified As to Content,

Sequence, Timing, and

Outcome

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Pragmatic Scientific Method

Rule # 1 All Work Shall Be Highly Specified

Hypothesis

Sign of

Problem

Response

The Person can do the activity asspecified and

If the activity is done as specified the

service or outcome will be defect free

The activity is not done as specified or

The outcome is defective

Determine the true skill level of the

person and retrain as appropriate or

Modify the design

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Before We Can

Improve a System We

First Have to StabilizeThat System

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Stabilization of theSystem Is

Accomplished By

Standardizing

Processes

Different Views of Reliability

110-10.9

10-60.999999

10-50.99999

410-40.9999

310-30.999

210-20.99

Sigmas

(approximate)

UnreliabilityReliability

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STRICU & MICU - POTASSIUM ADMINISTRATION TABLESee table for more details on things which influence K+ needs.

Markedly Increased K+

NeedsNormal Renal Function AND 1)High

U.O.>250 cc/hr OR 2)Loop Diuretics with

high U.O. (>150 cc/hr for 2 hours) OR 3)GI

losses>2500 cc/day (NG or Diarrhea) OR4)on Corticosteroids or Amphotericin B

Normal K+ NeedsNo Diuretics or High U.O

No Excessive GI Losses

No Coritcosteroids

No Amphotericin

Markedly Decreased K+

NeedsU.O.3.0 OR

On K+ Blocking Diuretics

(Spironolactone or Triamterine)

**Replacement Table for Low Potassium. May be used in patients eating a diet

K+ = 3.0 - 3.7

Replenish Mg deficits if

present

Give 80mEq K+ via GI tract AND

check serum K+in 3 hrs. (If GI tract not

usable, infuse*** K+ IV @ 10mEq/hr

AND check K+ 30 min. after infusion.)

Replenish Mg deficits if present


check serum K+in 3 hrs. (If GI tract

not usable, infuse*** K+ IV @ 10

mEq/hrAND check K+ 30 min. after

infusion.) Replenish Mg deficits if

present

Give 20mEq K+ via GI tract AND check

serum K+in 3 hrs. (If GI tract not

usable, infuse K+ IV @ 10 mEq/hrAND

check K+ 30 min. after infusion.)


K+ = 2.5 - 2.9


present


check serum K+in 3 hrs. May give in

Divided dose over 4 hours . (If GI tract


mEq/hr***AND check K+ 30 min. after


present


serum K+in 3 hrs. (If GI tract nok

usable, infuse K+ IV @ 15 mEq/hr***








K+ = < 2.4


present


check serum K+in 3 hrs. May give in

Divided dose over 4 hours . (If GI tract


mEq/hr***AND check K+ 30 min. after


present


check serum K+in 3 hrs. (If GI tract not









K+ = 3.8 - 4.4

ANDCardiac

Arrhythmiapresent or feared (e.g.

digoxin levels high)



usable, infuse*** K+ IV @ 10mEq/hr













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Give 60 mEq K+ via GI tract AND

check serum K+in 3 hrs. (If GI

tract not usable, infuse*** K+ IV

@ 10 mEq/hrAND check K+ 30

min. after infusion.) Replenish

Mg deficits if present using Mg

replacement protocol

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Potassium ProjectPercent of Unsafe Values In Critical Range

Critical is < 3.0 mEq/L or >6.0 mEq/L

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

< Critical > Critical

1996 1997 1998 1999 2000 2001 2002

10-2

10-3

Glucose Control All TEN Pts.Percent of Unsafe Values in Critical Range

Critical is < 60 mg% or >350 mg%

0

0.5

1

1.5

2

2.5

< Critical > Critical

Pre-Prot/94 Post-Prot/95 1997 1998 1999 2000 2001 2002

10-3

10-3

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2nd Rule In Use

How People ConnectEvery Customer-SupplierConnection Must Be Direct,

and There Must Be An

Unambiguous Yes-or-No Way

To Send Requests andReceive Responses

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Step 1 -

A Group of

Processesor

Procedures

Value Stream Map30,000 foot level

Requester

Intermediaries

Step 1 -

A Group of

Processesor

Procedures

Step 1 -

A Group of

Processesor

Procedures

Step 1 -

A Group of

Processesor

Procedures

Step 1 -

A Group of

Processesor

Procedures

Represents a Delay

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New Order

Set Needed

Work Group

Experts and

Knowledge

Engineers

Review by

Dev.

Team

(assigned)

Review by

IHC

Clinicians

Approval by

Dev. Team

Leaders

Activation

Trial in

Clinical

Arena and

Problems

found

CP Guidance Council:

Set Priorities

Value Stream Map Current Condition

30,000 foot level

M.D. R.N.

IHC Health Plans:

Define Specific Needs

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30,000 foot level


Work Group

Experts and

Knowledge

Engineers

Review by

Dev. Team

(assigned)

Review by

IHC

Clinicians

Approval by

Dev. Team

Leaders

Activation

Trial in

Clinical

Arena and

Problems

found

New Order

Set Needed

MD RN

New Order

Set Needed

MD RN

Work Group

Experts and

Knowledge

Engineers

(Dev. Team)

Trial in

Clinical

Arena and

Problems

found

Value Stream Map Target Condition

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3rd Rule In Use

How Pathways AreConstructed

The Pathway for Every Care

Process and Service Must Be

Simple and Direct

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Can You Imagine How Long

Toyota Would Tolerate Not

Having The Correct Part

Immediately Available When

Needed On the Assembly Line?

How Often Does That Occur In

Medicine?

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Patients Condition

Requires a Med.

Nurse

Alerts

Phys

Phys

Writes

Order

Clerk

Takes

Order

Off

Order

Sent

To

Pharm

Pharm

Verifies

Order

Tech

Prepares

Order

& Sends

To ICU

Request Made


30,000 foot level

4.5 h

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Patients Condition

Requires a Med.

Nurse

Alerts

Phys

Phys

Writes

Order

Clerk

Takes

Order

Off

Order

Sent

To

Pharm

Pharm

Verifies

Order

Tech

Prepares

Order

& Sends

To ICU

Nurse

Alerts

Phys

Phys

Writes

Order

With

Pharm

Pharm

Verifies

&

Sends

Order

Tech

Prepares

Order

& Sends

To ICU

Request Made


Value Stream Map Target Condition

30,000 foot level

Multidisciplinary Rounds

Communications

4.5 h

47 min.

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The Toyota Method

of Evaluating

Problems

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Tools Used to Support the

Culture at Toyota

Formal observation

A3 process Value stream mapping

Kanban Cards

Andon cords

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Define the Issue

Understand the Issue inDepth Background

Do a Detail Observation

Draw Current Condition:

Confirm It by Asking Others

Identify Areas of Waste

Identify Problems With CurrentCondition (Storm Clouds)

Analysis of Problems: 6-Whys

for Each Problem

Define the Issue

Toyota A3 Process QI - Rapid Cycle Process

Left Side

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Patient Flow From

MSICU to Acute Care

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Issue: The waste and delays

in care associated with

inappropriate stays in the ICU

environment.

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Background: For years we have

struggled with the problems of

patient flow through the ICUs.

This causes a lot of waste,

difficulty admitting patient who

need ICU and enormous

frustration for physicians and

nurses.

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Observation Method

Go and Observe The EnvironmentAround the Issue

Record Observation Carefully, Minute

by Minute

Study the Observation and Represent It

As a Picture

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Dr. Clemmers

Observation

Sheet

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Patients Condition

Meets

Discharge Criteria.

Current Condition

Physician

Writes D/C

Order and

Specifies

Receiving

Unit

Physician

Consults

with Others

About D/C

Pt. Continues to

Occupy ICU Bed

Inappropriately

Specified

Receiving

Unit Is Full

Patient

Transferredto New Unit

No

Disagrees

YES

Request Made

To Physician

Specified

Receiving

Unit Has

or Opensa Bed

Non-specified

Unit Is

Open

Undecided

Agrees

Physician

Agrees,

Disagrees or

Is Undecided

About D/C

Physician

Wants

More Data

Before

Deciding

= a Delay

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Agrees

Current Condition

Physician

Writes D/C

Order and

Specifies

Receiving Unit

Physician

Consults

with Others

About D/C

Pt. Continues to

Occupy ICU Bed

Inappropriately

Specified

ReceivingUnit Is Full

Physician

Wants

More Data

Before

DecidingPatient

Transferredto New Unit

No

Disagrees

YES

Request Made

To Physician

Specified

Receiving

Unit Has or

Opens aBed

Non-

specified

Unit Is Open

Undecided

Problem 5

Problem 1

Problem 3

Problem 4

Patients Condition

Meets

Discharge Criteria.

Physician

Agrees,

Disagrees or

Is Undecided

About D/C

Problem 6

Problem 2

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Why Do Physicians Need to Consult withOthers Before Discharging?

Attendings are not confident in the H.O. ability to make

such decisions or fail to communicate clearly with them

H.O. fear the attending will disagree because attending

sometimes rewrite their orders and fail to communicate

with them clearly

Attending afraid the consultant might disagree and do

not want conflict

Insecurity in their own decision making capabilities

Problem 1 Analysis

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Why Do Physicians Disagree with

Discharge Criteria?

Non-functional discharge criteria

They do not know what they are

Have not had input and therefore disagree with them They feel their gestalt is better than the rules

They use other non-definable criteria in making the

decision such as what is the staffing and care like on

the receiving unit, my work load today, H.O. coverage

Personal bias

Problem 2 Analysis

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Problem 3 Analysis

Why Do Physicians Need MoreInformation?

They feel the D/C criteria does not consider the

time component to describe stability

They feel a likely complication will result in

immediate death or disability

They feel the receiving unit cannot monitor

closely enough or handle the situation Lack of confidence in their early judgment

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Why Are There Big Delays in Getting

Discharge Orders on the Chart?

Physicians responsible for writing order not

available

With busy physician schedule writing the

discharge order is not a priority

Delays in communicating desire with H.O. or

other physician responsible to write the orders

Problem 4 Analysis

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Why Do Physicians Insist on a SpecificReceiving Unit?

They feel the care for their patients is inadequate

in other units

They like the efficiency of having all their patients

on one unit.

They know the procedures and processes on one

unit better than the other units and communicatebetter there

Problem 5 Analysis

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Why are the Specified Units

Frequently Full?

Inefficient early discharging practices

Poor planning and control of the surgery

schedule

No or nonfunctional discharge criteria

Problem 6 Analysis

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Barriers to Creating New Condition No agreed upon discharge criteria

Physicians refusal to abide by discharge criteria

Fear that patients condition may change despite

meeting discharge criteria

Insecure H.O. and controlling Attendings

Inadequate care on some units

Physicians perception that only one unit can

adequately care for their patients

Physician inefficiency when having patients on

multiple units

Desired unit frequently full

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Patient Transferred

to New UnitPhysician

Writes D/C

Order

An Appropriate

Unit Is Open

All Appropriate

Units Are Full

Pt. Continues to

Occupy ICU Bed

Inappropriately

Target Condition

Request Made To Physician

Patients Condition

Meets

Discharge Criteria.

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Agrees

Current Condition

Physician

Agrees,

Disagrees orUndecidedAbout D/C

Physician

Writes D/C

Order andSpecifies

Receiving Unit

Physician

Consults

with Others

About D/C Pt. Continues to

Occupy ICU BedInappropriately

Specified

Receiving

Unit Is Full

Physician

Wants

More DataBeforeDeciding

Patient Transferredto New Unit

Disagrees

YES

Request Made

To Physician

Specified

Receiving

Unit Has or

Opens a

Bed

Non-

specified

Unit Is

Open

Undecided

Physician

Writes D/C

Order

Patient

Transferred

to New Unit

An AppropriateUnit Is Open

All Appropriate

Units Are Full

Pt. Continues to

Occupy ICU Bed

InappropriatelyTarget Condition

Request Made To Physician

No

Patients Condition

Meets

Discharge Criteria.

Patients Condition

Meets

Discharge Criteria.

Combined

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4th Rule In UseHow to Improve

Any Improvement Must Be Made

In Accordance With a Pragmatic

Scientific Method, Under theGuidance of a Teacher, At the

Lowest Possible Level In the

Organization

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Toyotas Pragmatic

Scientific MethodThe Toyota System Creates a

Community of Scientists By

Defining Specifications,

Establishing Hypotheses and

Continually Testing Them and

Measuring the Outcomes.

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Learning Line ConceptProblems are used to improve the system

Problems are recognized immediately and help

sought. (Problem solving is a team sport)

Help is immediately available

A counter-measure will be instituted immediately

to get to the patient their needed care

The Socratic method is used (the 6 whys) to find the

root cause and a final solution

A permanent solution will be instituted

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The Scientific Methodof Improvement

All Changes Are Discussed With

Immediate Supervisor, Documented

and Outcomes Measured

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Draw a Target Condition

Measure the Current Condition

Counter Measures:

Plan the Counter Measures

Test the Countermeasure

Measure the Results

Follow up:

Set the AIM

Set Up a Measurement System

Develop a Change Concepts

Plan

Do

Study

Act


Right Side

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Redo Counter Measures:

Plan the Counter Measures:

Test the Countermeasure

Measure the Results

Follow up:

Develop a New Change Concept

Plan

Do

Study

Act


Right Side

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The Toyota System Discourages

Command and Control

Environments.

It Stimulates Workers and

Managers to Engage InExperimentation That Is the

Cornerstone of a Learning

Organization

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How to Create a Learning

Environment That Thinks Lean Push the Processes Down to the Front Line

Recognize Problems

Do Observations

Approach All Problems As a Team, No More

Workarounds

Stabilize Your Processes

Use Toyotas Four Rules in Use

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