A Practical Guide to Applying Lean Tools and Management Principles to Health Care Improvement Projects 3.

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ROSS W. SIMON, BA; ELENA G. CANACARI, RN, CNOR www.aorn.org/CE

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 identied into logical groups and prioritize the groups by impact and difculty. Leaders must manage action items carefully to instill a sense of accountability 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.

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

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire January 31, 2015.
doi: 10.1016/j.aorn.2011.05.021

gram coined the term Lean to describe Toyotas 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 improves workow by reducing waste-related delays, workarounds, and rework. Lean improvement focuses on increasing value for customers, both internal and external, across the entire value chain as viewed from the customers
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SIMONCANACARI 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 solving and process improvement. We had the opportunity to improve the OR breakdown process for hip procedures. Inappropriate breakdown procedures were resulting in increased costs, and we realized that we could potentially improve patient, surgeon, and staff satisfaction by addressing such problems as

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 valueadded activities. Patients are key external customers to health care organizations. The patients value chain begins when the patient enters the surgeons ofce. 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 bioburdenladen instruments coated with an enzymatic spray to facilitate cleaning. Therefore, departments can be both internal customers and suppliers. 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 2 human development.

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 conducting a Lean process improvement project, from dening 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 principles 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 misunderstanding 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 approach for solving complex problems, especially in opportunities that require an interdisciplinary effort. Jargon is often used in these articles, most

For the Lean approach to work, leaders must create a favorable environment in which problems are recognized as opportunities for improvement. People are not problems, they are problem solvers, and emphasis is placed on nding solutions to problems rather than assigning blame. Lean principles help perioperative leaders improve processes with a set of management techniques that dene 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 Medical Center, Boston, Massachusetts, from Janu86 AORN Journal

LEAN MANAGEMENT TOOLS AND PRINCIPLES commonly Japanese production-line terms such as jidoka (ie, the ability to stop production lines in the event of problems such as equipment malfunction or quality issues), poka-yoke (ie, mistake proong), and hoshin kanri (ie, a strategic planning process), which adds a layer of confusion rather than enhancing understanding. In our project, 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 published 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 supervising people), driving out fear, breaking down barriers between departments, and transforming the organization, which is everyones job, not just that of managers.

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formed. Lean approaches help managers recognize and reduce the waste in processes. Wastes are activities that add no value from a customer perspective, including

Lean theory is rooted in the scientic method and the Plan-Do-Check-Act (PDCA) cycle,4 originally developed by Walter A. Shewhart, a Bell Laboratories scientist who was Demings friend and mentor. The PDCA cycle is a four-step model for carrying out change: Planrecognize an opportunity, plan a change, and estimate the impact of the planned change. Dotest the change; carry out a small-scale study. Checkreview the test results and identify what you have learned. Acttake 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.

Waitingwaiting for the next event to occur or next work activity Motion unnecessary movement by employees in the system Transportation unnecessary movement of the product in a system (patient, specimens, materials) Defectstime spent doing something incorrectly, inspecting for errors, or correcting errors Overprocessing doing work that is not valued by the customer or caused by denitions 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

The PDCA cycle is repeated over and over to continuously improve a process. Lean thinking helps dene both what has to be done to solve a problem and how work is per-

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 members 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 capacity to do more value-adding work, such as providing patient care. When drafting the project charter, henceforth referred to as the scope statement, involving individuals who have knowledge of the problem or opportunity and also have a stake in its solution helps ensure that there is a clear understanding of all aspects 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 successful start rather than wasting time at the rst few
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SIMONCANACARI 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 additional resources are needed, the leader obtains them. If team members do not volunteer to complete 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?

meetings identifying what the rst steps of the project 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 experience 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 according to the results. As dened in the PDCA cycle, the results attained after corrective actions 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 focused on achieving process perfection over time, not necessarily on the rst 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 complex 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 easier 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
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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 facilitators responsibility. Table 1 describes some key facilitation techniques that help improvement teams stay focused and productive. A dictatorial leader can deate morale so that members want to abandon the project; a good leader energizes the team. Likewise, the team can ounder 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 facilitator met before one meeting and developed a plan to ask the team whether every instrument in a pan of instruments was needed. The team subsequently 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 reduced an ergonomic hazard and decreased unnecessary work and related expenses in the CPD and the OR. Having a standard problem-solving process is essential. This process includes eight steps:

LEAN MANAGEMENT TOOLS AND PRINCIPLES 5. 6. 7. 8.

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TABLE 1. Facilitation Techniques

Prepare for the meeting Arrive to the team meeting room earlyset 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 ip 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 ip chart and ask Is this correct? Use the same technique when adding any information to the activity scorecard. The ip chart marker is a powerful instrument; when the facilitator writes on the ip chart, team members become engaged and galvanized. Ask questions Use the Socratic techniquedo not tell, ask: Would it make sense for us to . . .? Should we consider . . .? Use ow diagrams Make processes under discussion visible as ow diagrams. Dene area layouts clearly When discussing the physical layout of an area, use the ip 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.

prioritizing problems in an impact difculty grid, managing action items with an activity scorecard, monitoring progress of key action items during implementation, and 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 dened, understood, and accepted. Step 1 of the improvement process requires that the management team clearly dene the details of the project with measurable and challenging yet achievable goals. A scope statement (Figure 1) that contains a clear denition 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 inuence the success or failure of a teams project. The scope statement should not be developed by one individual. This could be considered cubical engineering one person attempts to dene and resolve 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.

1. 2. 3. 4.

dening the scope statement, identifying the current process and associated problems using a value stream process map, transferring the identied problems to a cause-and-effect diagram, organizing the problems into logical groupings in an afnity diagram,

Key elements of the scope statement include the following: background justication; quantiable goals; a target completion date; suggested approach; membership including the sponsor, leader, facilitator, core members who are expected
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Figure 1. An example of a scope statementa 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 justication for the project, goals to be accomplished, a target completion date, metrics, team membership, and simplied process ow.

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LEAN MANAGEMENT TOOLS AND PRINCIPLES to attend every team meeting, extended members who are brought onto the team as needed; and macro-ow, which is a simplied, processow diagram of the current state, typically consisting of about six steps.6 The macro-ow 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 process needing improvement. Although we did not include a macro-ow in the scope statement for this particular project, typically it is a standard element of a scope statement. Lean improvement projects are not just performed by a select few champions in the organization, 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

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Value Stream Process Map Step 2 requires that improvement team members prepare a detailed, process-ow 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 process steps in the value stream process map for our project. The rst 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 examples of a problem and an opportunity for improvement we identied while listing process steps. Process step #32: Central processing department personnel pick instruments and disposable 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 attendant in sooner to assist with patient transfer and to be available for turnover.

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 specic 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 problemsolving tools; an OR educator; the perioperative project director; surgeons; and a surgical technologist.

Cause-and-Effect Diagram During step 3, improvement team members transfer all problems identied 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 problem being solved or the opportunity for improvement? Team members place each problem next to the appropriate rib. Standard categories include methods, materials, manpower,
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Loaner instrument and supply kits are not always sterile and ready to use.

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

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 department to get the bed. Possible delay depending on whether the attendant 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 basement but sometimes there is not a bed available in the basement.

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 coordinator to nd out which rooms patients will go into and takes beds to the assigned ORs for each patient. 36. Anesthesia professional completes the preoperative form and the anesthesia consent form.
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 available when needed because they had not been notied of the need or they didnt arrive early enough.

Biggest delay: lack of bed availability affects everything downstream.

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

37. Anesthesia professional places IV and other invasive lines.

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

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

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SURGERY IS PERFORMED

The check box signies that all equipment is available for the procedure. It is not a room readiness checkbox. When the timing of the check is delayed, patient ow 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.

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 prepares equipment for the procedure.

PACU workow for providing beds and oxygen holders and cylinders is not always coordinated with OR needs, which can cause a delay.

41. On the day of surgery, circulating nurse checks all of the equipment on the 1st time primary hip procedure carttypically, no problems are encountered with primary hip procedures; problems are usually conned to revision hip procedures.

43. Circulating nurse and surgical technologist prepare the room for the procedure and ensure that there are not any roadblocks.
Instrument availability can be affected if booking information is not communicated to the OR clinical advisor; resources may not be keeping up with demand.

44. Surgeon closes the incision. 45. Scrub person puts the instruments back into the pans.

Figure 2. Continued

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Methods
One day before surgery, orthopedic ofce personnel conrm 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

If there is not an attendant in the holding area, the postanesthesia care unit clinical advisor should call the OR resource nurse to determine if the OR or the transport team should provide the bed.

Holding area A is undersized.

What causes delays in room breakdown?

Lack of case pick location Sometimes the need for intraoperative (ie, a specic location x-rays and autotransfusion are not added [eg, shelf] where supplies to the OR schedule, which may require a are stored) in the central workaround to ensure availability at the processing department and right time; if the clinical advisor does not add this information to the OR schedule, in the OR can cause delay. it may be missed and could cause services to not be available when needed.

Environment

Materials

Machinery

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

machinery, and 7 the environment.

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 problems, some of which may be very signicant. The next step is to amend the value stream process map. For instance, in our project, after we transferred the problems to the cause-and-effect diagram we identied the problem of bed availability or, specically, the lack thereof.

helps identify a few strategic themes for problem resolution so the team is not trying to address many individual problems or symptoms. 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).

Afnity Diagram Step 4 involves organizing the problems into logical groupings in an afnity diagram (Figure 4). This reduces the number of problems to manageable groups and helps dene root causes; eliminates redundancy in problems identied during the preparation of the value stream process map; ensures that solutions developed will address a broad scope of related problems; and
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Impact Difculty 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 difculty of implementing solutions to resolve 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/

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Instruments:
Loaner Policy Loaner instruments not received on timeneed loaner instrument guideline.

Attendant:
Possible Delay in Bed Availability Postoperatively Possible delay depending on whether an attendant 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 basement; however, sometimes there is not a bed available 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 surgical 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 afnity diagram in which grouping seemingly disparate problems into logical groups helps the team manage the many problems and opportunities for improvement identied and develop corrective actions. This is a simplied diagram in which only one problem/opportunity for improvement is shown for each category; in reality, there were multiple problems in each category.

difculty analysis indicated that we should start developing solutions for issues related to instruments to make rapid and meaningful progress toward meeting the teams 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 dening 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

High

X Attendants

X Instruments

Impact

X Central Processing Department Dirty Elevator

X Holding Area

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.

Low High Difculty Low

Figure 5. An impact difculty grid used to prioritize the groups of problems identied in the afnity diagram according to the impact on goal attainment and difculty to solve.

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 dening the planned work. Making this contract visible during
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Attending 6/21/10 Meeting: Updates in BLUE ID TITLE ISSUE(S)

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

NEXT ACTIVITY
Remind attendants not to take tables without red tracking sheets.

Priority

Who

TARGET COMPLETION DATE

STATUS
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 identied with a red tag. 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.

Sharps data

Medium

OR nurse manager

7/26/10

1
Obtaining loaner equipment and supplies affects set-up times so need to develop a loaner policy for contractors that denes expectations. Without control of loaner items, a domino effect can occur in CPD. Having a workable, enforceable policy will help relieve pressure on CPD. 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. Work with the senior materials management specialist to ensure complete labeling of loaner kits.

Loaner policy

Medium

Project director, perioperative services

7/26/10

Auditing

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

Towels will be included in metrics. Quality improvement sheet has been designed. Associate chief nurse, perioperative services and RN clinical advisor

Medium

7/26/10

3
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 Succeeded in getting doctors to use curettes with black handles. OR clinical advisor and core technologist

Physicianspecic instrumentation

7/26/10

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

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 identied 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 implementation 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 improvement project is planning actions that will sustain the gains that the team has achieved. All
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too often, realized improvements are lost when the project closes and team members are disbanded because no plan was put in place to embed 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 improvements slip outside the desired parameters. Turnover 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 responsibilities 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 process. Updating position descriptions, policies,

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Oct 26
Value stream process map Cause and effect diagram Revised and updated preference lists Hire open attendant position Central processing department 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 physicianspecic instrumentation Audit case carts Hire the new position of senior material management specialist Transfer knowledge to other procedures Practice Council recommends creating separate guidelines for the breakdown and set-up processes

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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 Complete Re-label shelves

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

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

and standard operating procedures helps ensure that the improvements live on, as will making supervisors responsible for maintaining and improving 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 nd supplies in the OR. Time was often wasted searching for supplies, especially for someone lling 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 members met in small subgroups between the regular 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 sessions to check on the progress of tasks and decide 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 benet from the structured Lean approach, which has been successfully applied to many other Beth Israel Deaconess Medical Center
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Ambulatory Takeaways Applying Lean Management Principles in an Ambulatory Surgery Center The basic principles of Lean management are applicable to all facilities where surgical and other invasive procedures are performed. These tools and techniques can be applied in ambulatory surgery centers (ASCs) in a more simplied but equally effective manner. The internal and external customers of an ASC are similar to those of an acute care facility, but often the stakeholders have different motivations because of an ASCs organizational structure, ownership, and customer base.1 For example, in a traditional facility, the surgeon is a provider, whereas in an ASC, the surgeon also may be an owner or investor in the ASC as a business. In an ASC, the patients value chain begins when the patient enters the surgeons ofce, which is especially true when physician-owned ASCs are contiguous with the professional medical ofces. For ASCs, Lean processes can be used to monitor quality indicators as a result of regulatory requirements or quality indicators that the ASC governing board has selected to document efforts and outcomes (eg, patient satisfaction, infection prevention). Waste and redundancy are high priorities for all perioperative departments, but in a physician-owned ASC, there is an additional incentive to use Lean processes to nd cost savings. Reimbursement for ASCs is a at, procedurebased, xed amount. Therefore, any additional high-cost items (eg, implants, medications, newly released products) must be evaluated in a thorough multidisciplinary manner as described in the Lean process. On the other hand, acute care, inpatient perioperative services are reimbursed based on time-related (ie, minute) charges for the OR, anesthesia services, and direct costs of supplies with approved markup beyond cost. In hospital-based outpatient departments, reimbursement is also procedure based, but ASCs only receive 65% of hospital-based outpatient rates.2,3 As in all facilities, miscommunication is often the root cause of failures. Because there are fewer staff members in an ASC, it is imperative to evaluate the workow and patient care rendered using a Lean process so that staff members who are very familiar with one another do not develop unsafe or inefcient workarounds.4 It is important to use the Lean process when implementing regulatory compliance processes, such as mistake-proong activities (eg, time out, read back and verifying verbal orders, no passing zones).4 In an ASC, the processes and tools may not be as complex as in the acute care counterparts but can be equally effective in quality improvement. Deborah S. H. Mathis, MS, RN, CNOR, CRNFA, is the director of surgical services at Renue Surgery Center, Brunswick, GA. Ms Mathis has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.
1. Hickman DS. The feasibility of introduction of surgical technologists to a rural community hospital: an analysis for surgical services [masters thesis]. Wilmington, OH: Wilmington College; 1999. 2. Ambulatory surgical center payment. Centers for Medicare & Medicaid Services. https://www.cms.gov/ascpayment. Accessed October 1, 2011. 3. Stegman MS. Hospital outpatient surgery versus freestanding ASC costs and reimbursement. J Health Care Compl. March/April 2005:39-41. 4. Hickman DS. Safety: talk your way to a culture of safety. Outpatient Surgery Magazine. http://www.outpatientsurgery.net/issues/ 2009/12/safety. Accessed October 1, 2011.

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LEAN MANAGEMENT TOOLS AND PRINCIPLES projects. Positive results from our project included the following:

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A standardized hip procedure breakdown process was developed and implemented. Room turnover time was decreased by 10 minutes. A process for safely managing sharps was developed 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 ow in assembly of kits in the CPD was developed and implemented. The number of surgeon-specic 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.

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 organization benets by tapping into a rich reservoir of talent and experience to solve its most challenging 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-checkact 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: owchart denitions 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.

We also learned valuable lessons, such as having all involved disciplines and key stakeholders participate in the project. This allowed everyone to gain an understanding and an appreciation of each others 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 structured problem-solving methodology, there is no limit to what they can accomplish. The Lean approach is simple and straightforward. Using cross-functional teams guided by Lean principles and tools to solve complex problems in a health care setting allowed employees, patients, and the organization all to benet. Employees, who for years have tried unsuccessfully to inuence positive change through the manager/

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 Japans Competitive Success. Columbus, OH: McGraw Hill; 1986.

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

Isachsen O, Berens LV. Working Together: A PersonalityCentered Approach to Management. Lausanne, Switzerland: Institute of Management Development; 1988. Katzenbach JR. Teams at the TopUnleashing the Potential of Both Teams and Individual Leaders. Boston, MA: Harvard Business Publishing; 1998. Katzenbach JR, Smith DK. The Discipline of Teams. Hoboken, NJ: Wiley; 2001. Kobayashi I. 20 Keys to Workplace Improvement. London, England: Productivity Press; 1990. Madison D. Process Mapping, Process Improvement, and Process ManagementA 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 RabbitHow Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win. Columbus, OH: McGraw Hill; 2009.

Ross W. Simon, BA, is a senior management engineer at Beth Israel Deaconess Medical Center, Boston, MA. Mr Simon has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article. Elena G. Canacari, RN, CNOR, is an associate chief nurse of perioperative services at Beth Israel Deaconess Medical Center, Boston, MA. Ms Canacari has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.

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EXAMINATION
CONTINUING EDUCATION PROGRAM

3.6
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A 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. 2. 3. 4. Describe how Lean improvement focuses on understanding the customer. Discuss how Lean management principles can be applied to health care. Explain how Lean management principles are used to improve quality. Differentiate between the Lean management leadership roles in a quality improvement project. 5. Identify key Lean management tools. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination 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 manufacturing and health care. a. true b. false 3. Wastes are activities that add no value from a customer perspective; these include
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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 rst steps of the project.
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c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

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 perfection 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 denes the details of the project. 2. contains a clear denition of the problem to be solved. 3. identies measurable goals. 4. includes the voice of the patient if possible. 5. is developed by one individual from the management team. a. 1 and 2 b. 2, 3, and 5

8. Organizing the identied problems into logical groupings is done using a/an a. scope statement. b. impact difculty grid. c. afnity diagram. d. cause-and-effect diagram. 9. Managing action items by clearly dening all corrective actions is done with the use of a/an a. implementation plan. b. activity scorecard. c. value stream process map. d. impact difculty 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 meetings 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 declared afliations that could be perceived as potential conicts of interest in the publication of this article.

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LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM

3.6
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A Practical Guide to Applying Lean Tools and Management Principles to Health Care Improvement Projects

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 understanding 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 leadership 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 knowledge 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 reading 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/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect 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 recertication, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers 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 certicate of completion.

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