I'll be talking on some of the basic fundamentals to describe what the LEAN approach is and how it can be implemented in the radiology department, to describe the fundamental principles, the basic approach to LEAN, and to show how these apply to our imaging practice, to discuss the current practice of radiology and to show how this is so well suited towards using LEAN as one of the improvement approaches, and then to show some examples of LEAN in our imaging environment. So let's just start off right at the beginning, for those of you who are not too familiar with LEAN, to put this in perspective. What is LEAN? What do I mean by LEAN? LEAN is not an acronym. I do not like the word LEAN. I typically prefer the concept of continuous performance improvement, which is what it is. LEAN really is a focus on adding value by eliminating all forms of waste and taking the customer perspective in. We are surrounded by waste in our imaging environment. Think of all the examples of excess inventory, not just equipment, but catheters, contrast materials. Think of the fact that most of you have a small committee dealing with expired inventory. Think of the impact of overburden, stress, repetition. Think of the ultrasound technologists who are dealing with carpal tunnel syndrome because of imaging too much. Are they taking too many images? Are we imaging inappropriately? Are we imaging too long? Are the patients of such a size we need to press harder? Are the transducers of different size or inappropriate depth? So lots of ways in which lots of examples of LEAN. Think of the number of variations and the lack of standardization in your process. I work in an academic environment and we struggle every year trying to teach our trainees how to protocol CT scans. Think of the immense variation in how a group of people would actually protocol a single study based on information. There are lots of different examples of waste in our workplace. LEAN in essence is a combination of identifying these, recognizing opportunities for getting rid of waste, and then putting steps in place to try and eliminate these. There is a very, very intense focus on customer value in LEAN. It's very important that we don't try and decide ourselves what it is that the customer wants. We need to know exactly who our customers are. It's not just the patients. It's the referring doctors. It's the patients. It's the schedulers. You name it. We have many, many different customers or clients and we need to know what it is that they value. We cannot surmise what this value is. We need to know. In essence, what we really need to do as part of LEAN is to get our blinkers off. We need to learn how to walk around and to observe and to get our blinkers off and to identify and ask questions and to come up with solutions. If we're going to work in our imaging environment with our blinkers on, we are seldom going to result in any meaningful improvement. So let's take a walk around the radiology department. This is a generic department. I took my camera and I walked around my department last week and I observed. I went to the waiting room. Looks pretty nice. There's art on the walls, flowers, lighting. The things in the waiting room that we think the patients want, we've never asked them. We think they like the art. We think they like the flowers. They don't have allergies. These actually are real flowers. They're probably bees and flies and aphids and things growing on them. We like the chairs. We think they're comfortable. It's a quiet room. It's clean. It's safe. It's private. We think that's what the patient wants. But we've never actually asked the patients. When we do ask the patients, boy, we hear it from them. They often don't like to have seats right next to other seats. But if you look at this in more detail, why is the waiting room empty? Why do we have a waiting room at all? Why are there so many chairs? The modern approach to LEAN is to look at ways of improving flow to the extent that a patient will enter your imaging environment and go straight to wherever the imaging takes place. One really need not actually have waiting rooms if you can design workflow in such a way to optimize it. So it's over when we're showing you waiting rooms, but in fact in the ideal situation you really don't have waiting rooms at all. Patients in a waiting room feel like they're waiting. Their time is being wasted. The parking is going to be more expensive while they sit there. LEAN is a way of getting rid of waiting. So why waiting at all? I walked into our waiting room. Again, these are ergonomically sound, pretty expensive tables like we've all got. Chairs seem to be ergonomic. There's issues with lighting I noticed. There's glare on all the screens. Granted, I'd switch the lights on especially. They're keypads. Who's taking care of all the bacteria on the keypads? Do we have a system for cleaning these? Are there wipes on the tables to clean these? Who's taking care of all these things? Why is there a printer sitting at the workstation? Do we really need printers? Is this not a waste of ink, not a waste of paper? Haven't we gone digital in the work environment? All I'm trying to illustrate is how by walking around and asking questions, observing, you can really identify lots of ways of eliminating excess or waste and making things work far smoother. What about HIPAA violations? Can't we just walk in here, see names on the screen, see studies on the screen? No one asked me for an ID badge at the entrance. We have people walking into our reading rooms and announce they can go up and look at studies on Pax. That's pretty much a HIPAA violation in our environment. We have to think about all of these things as we start looking. It's empty. Why is there no one sitting at the Pax workstation? Well, maybe this was 7 o'clock in the morning. Maybe this was 6 o'clock in the evening. What is the average use? We timed use on our Pax workstations, 30 hours per week. We have people sitting continuously at the Pax workstations, which only translates to 4.2 hours per day. We all know what it costs to buy a new Pax workstation. Forget about the license, the equipment, the software, the chairs, the tables, the lighting, the soundproofing, 4.2 hours a day. Almost everyone in my section chief comes to me with great regularity claiming they need more Pax workstations. Again, use the data to make rational decisions and to eliminate excess waste. In this case, waste is that equipment is not being used. What is on the screen? I looked at the screen. This was a neuro study. Look at all the series in this neuro study, 1,730 images. This might be a pretty standard neuro MRI study in an academic environment for a particular entity. But to me, it seems like an unbelievable number of series. Can you imagine the time it took to acquire this, the technologist's time, time to send this to Pax, time to interpret, the number of opportunities that are being made to make mistakes? That's pretty much what it is. What I mean would be to look at this and ask how many of these series really are necessary? How many are contributing to and adding value to the patient's diagnosis? That is what Lean is all about. I walked into another reading room to see our residents working. Here's the residents at the workstation. You can see nice images. Everything seems to be ergonomically sound, aesthetically pleasing, clean workplace, few pieces of paper. And residents seems pretty happy. These are our productive residents, productive physicians. Pax is working. That's always a good thing. It's a nice ergonomic environment. But there's food in the workplace. Why is there food in the workplace? Do you all allow people to drink coffee at your workstation? What about workplace policies? How do you announce these policies to new trainees when they begin the year? How do you change policies? How do you update policies? How do you monitor compliance with policies? These are the types of questions you can ask when you walk around a department with your blinkers off trying to identify very simple opportunities for improving what you do. This in essence is a way of identifying PQI projects, practice quality improvement projects. But really what the question I wanted to ask over here is why this resident had such a large glass. More important, what is in that glass? So our residents have a pretty nice work environment and we try to keep them happy. And the question I have for all of you in the audience is, is this a bare glass, half full or half empty? In lean, that really isn't the question you want to be asking. In lean, the glass is never half full or half empty. The glass here is twice as big as it needs to be. You need to have the right glass. You have to have the right glass because that's waste. You're thinking and spending too much time wasting on this. You need to have the right size glass. So the glass is too big. That is what lean thinking is all about. So how would I define lean thinking? It's a culture, a culture shift which takes five to seven years of constructive and engaged inquiry. You don't want to walk around like a hall monitor looking for issues. You want to go around understanding, engaging the workers in the workplace to help them come up with questions that can result in local improvement. You want to go and look but you need to be allowed to observe and seek what's going on. It's continuous performance improvement. It's a culture of inquiry and continuously looking for ways to add small incremental steps to what you do, participating in these small incremental steps, working in functionally flat teams. By that I mean you don't have someone on top who's really letting everything trickle down to others. You all have the same voice. You all have the same opinion. Everyone's voice counts. Everyone's thoughts and input count. There's no one in charge. You all count equally. In a radiology environment where it's a nurse or a technologist or a physician or a transporter or a scheduler, you all are equally important to the process and you all can contribute equally to how things can be improved. It's always striving to make things better. Depending on what your customers value, but again, you need to know who your customers are. You need to ask your customers what they value and you don't just need to listen to them. You need to hear what they're saying. Another very important concept in LEAN, don't just listen but actually hear what they're saying and respond to what you're hearing and to know what they value. It's also a relentless effort to eliminate all forms of waste. Why is it so good and why is LEAN so applicable to radiology? Again, think of how important our customer service is becoming. In the new healthcare environment, in the ACO world, we are going to get paid for how we measure our value contribution and how our customers value our service. The value paradigm is here. We need to add value and know what value is and measure it, respond to it. We are always looking for continuous improvement opportunities in imaging. The technological advances are almost happening too rapidly for us to keep up with. We need to catch up with that. There's enormous variation in complex processes. Think of how complex dose management is, protocoling, new equipment, enormous opportunities in radiology. There are also enormous amounts of waste. Think of the equipment we're buying, the contrast, the catheters, the excess movement, the excess amount of everything we use. Again, very amenable to radiology. We are very dependent on teamwork. Many of you as radiologists in the room are probably doing peer review but you're probably simply doing peer review on your own radiologist colleagues. Are you all peer reviewing what the technologists are doing? Are you peer reviewing the actual equipment and the technical components? Are you peer reviewing how the nurses are functioning? Are the nurses and technologists peer reviewing what you do? That really is the teamwork and how you can get effective feedback. It's also a focus on improving efficiency. We're all trying to scan patients quicker. We're all trying to get our reports out quicker. We're all trying to scan more patients more effectively to add value. Again, another example of why radiology is so appropriate here. We're totally dependent on equipment and it really does require knowledgeable leaders to drive this process. For those of you interested in this topic more, there is a paper in Radiographics I would refer you to and a lot of the questions to the quiz come straight out of that paper. For continuous efforts to succeed, what you see over here is a little red star. The red star over here on every one of the slides, it's really a hint that there's a question on the paper on that slide. For continuous efforts to succeed, you require lean leadership. What do we mean by lean leadership? It's a chain of support rather than a chain of command. You don't want someone on top who's barking down commands to you telling you what to do. You are a support chain where each of you is playing an equally supportive role. You each need to have a voice and you each need to be able to speak up. You cannot depend on any single individual. Look what happened in the Greek ferry disaster when you had one captain in charge who wasn't on the deck at the time and look what happened to this ferry. One person was in charge, no one was speaking up, there were not others willing to step up. Rules need to be continuously evaluated. Just because we have leadership rules doesn't mean they're correct. The co-pilot checklist in an airline, don't touch anything, keep your mouth shut. Well, this might seem funny but actually this is exactly what happened in the Asiana air disaster in San Francisco. We had a cultural shift within the cockpit where certain people were unwilling to speak up and to share their concerns that this aircraft was coming in too low and look at the impact of that. So again, everyone should have an equal voice and everyone should be very willing to speak up and share their concerns. What are the essential components of lean? These are the tools that I'm going to share with you as the rest of this talk. First of all, the use of idea systems, ways of collecting ideas from everyone in the workplace. A very visual system, people need to know where they are on projects, what's happening in a very visual manner. If it's to standardize work, minimize variation, think how we're all starting to use checklists now in radiology. Mistake proofing, everything we do to try and reduce the chance of errors, universal protocol being applied to actually reading out a scripted timeout, eliminating waste in its many forms, designing the workplace for flow, and you're going to hear the third talk this morning where Paul is going to focus very much on lean architecture and how we can improve our workflow. Think of how inefficient this meeting is where most of you are going to go out of this room and then walk across to the Lakeshore building and then come back to another talk over here. We're all getting a lot of exercise, that is good. But boy, if you think how it's scheduled, we're going backwards and forwards from hall to hall. We need to design these workplaces so there's minimal motion between where it is we're trying to be. And then of course, gember walks. And a gember walk really is using the Japanese word to go and visit where the work is actually being done, to go and see and to teach where the work is being done. So what is a gember walk? It's essentially going to where the value is created for the customer. In the motor car industry, the value is created on the shop floor. In radiology, the value might be created in the ultrasound imaging suite or in the interventional suite. It's where the images are taking place. It's where you're acquiring those. From certain perspectives, the value might be in the reading room. We need to establish a routine rather than a per diem process. I do gember walks every Tuesday morning. My department knows that I'm walking around and I'm not going to observe. I'm taking people with me. Hi Ella. And I'm going to go and see exactly what's happening, ask questions. I'm assigning what. I want people to give me feedback, to tell me what's happening in the workplace, to tell me how I can help them make small improvements. State your purpose. Don't go as a small little walking team, you know, as a little examination team like a joint commission visit. You're here to see how you can improve throughput on a CT scanner. You're seeing here if people all understand how to call emergencies. Go and explain exactly what you're doing. Don't have great ideas. Go with small little questions, small things that can be solved, little steps. Provide outcome and follow up, not consequences. There should never ever be any punitive consequences at all. The minute you introduce any punishment in any quality improvement process, the improvement process essentially is terminated at that point. You need to go there and provide useful constructive feedback for how they can improve. Go and see what's happening, share your expertise, and teach people, and then learn from them as well. And again, this is very important. Learn to listen to them, but hear what they're saying. Don't just provide a set of ears. Hear what they're saying. Give them feedback in a week or two in response to the comments that they've given you. And then structure the visit as a process. Go with a specific process in mind that you're going to collect data. Learn to seek opportunities, and collect and manage the right information, and again, provide constructive feedback. So all of these are lessons that I've learned the hard way. I used to go and do Gamber Walks. People would get a little bit nervous, and I've learned all of these from feedback from people at the workplace, usually our technologists and nurses and some of our residents. And it's become very much a learning process for me and a constructive engagement for all of us. And here's a perfect example. We've got a nice IT division in our department. They make dashboards. We've got dashboards on our iPads. And this was a system. They were actually monitoring timeouts. They were looking at universal protocols, as we're all supposed to for joint commission. And we had a very nice dashboard, and everyone was hitting 100%. You can see over here, in every single modality, we're 100% compliant with everything. Well, in essence, that's really not very helpful if you're 100% at everything, because A, you know that we're not 100%. It means that the data collection process is wrong. You're not asking the right questions. Part of the Gamber Walk is to know why you're doing it. Who is supposed to be collecting data? When are you doing it? If you're going to do a walk around the reading room at 6 o'clock in the evening, in our place, it's going to be empty. You know, it's often more important to go around at 8 o'clock in the morning to see who's at work, and that often will stimulate people in our situation coming in early. Go to the right place and know what exactly you're doing. Just by looking at this, we knew we were asking the wrong questions. This was a junior nurse doing the observations who was very nervous about giving a radiologist anything less than 100%. It was very, very unhelpful. Now we have radiologists doing the Gamber timeouts. We have our residents doing these timeout observations as part of their PQI resident projects. If you're getting 100%, and if you are truly at 100%, move on to a different metric. Move to a different project, because it really means you've attained perfection, which I doubt exists. So why are we doing all of these things? Is it just for the Joint Commission? No. It's to teach processes to your faculty members, to all people in your department, to teach them to ask questions, and to teach them to seek improvement. Plan to collect impactful data. This was not impactful data. And maybe the customers themselves should be looking at us. A lot of departments now are struggling to come up with ways of seeking feedback from their patients. Ella gave an unbelievable talk last year, actually, on customer service. We all need to get feedback from our patients in interventional radiology, and no one's really come up with a great system yet of asking a sedated patient straight afterwards what the procedure was like. So ask your customers. We use a system of a so-called seeing with other eyes. We use mystery shoppers, become very popular now. These are all patients, ex-patients, and they've all served as mystery shoppers, and it's great. And these are just some examples of what they do. They visit our website, and boy, they're not shy to tell us what they think of our website. They try to call and schedule a specific study. Hi, I'm Mr. So-and-so. I want to get a biopsy of my left lobe of my liver. They give us very good feedback about cleanliness of our waiting areas, our parking, our hospital, our cafeteria, you name it. They're very good at asking directions. They're listening for personal health care information. They're listening in the registration areas. They ask questions about dose. They don't care who they ask. They expect everyone in our department to know about dose, and if someone doesn't know, they expect that person to know who they can be pointed to. They try to speak with specific radiologists. They'll actually come in or call and say, I want to speak with Dr. Kriscoll who read my report, and they want to know that everyone knows how to find me so I can talk to the patient. And they also try to understand a report, and they call in or they visit, and it's become very, very helpful feedback for us. Again, you really need to hear the voice of the customer in this setting because you can get some incredibly helpful feedback from them, each of which, if appropriately managed, can lead to continuous performance improvement. Again, each of these, I think, is a wonderful PQI project opportunity. Some feedback we got from our patients. Here was someone had taken a walking stick and shoved it in behind a door because the door was broken, and here we had this. This was what one of these people showed us. And this really is what I would call a Band-Aid solution. So this patient actually said to us, it was tacky, cheap, and uncaring, and we had to hear that. I couldn't say it's not uncaring because I thought the door was now open, it's easier for wheelchairs and stretchers to go through. If a patient says it's uncaring, it's uncaring, and you need to respond to that, and you need to hear that and do something about it. It's very easy. Pick up a phone, and within a few hours, the door is repaired. So this is really a Band-Aid solution, and the Band-Aid solutions radiologists are not great at. But our trainees and our techs are brilliant at this, and we need to know a way of actually measuring these Band-Aid solutions. How can we capture these? And these are the so-called idea systems, and we have idea systems liberally scattered throughout all our modalities. It doesn't matter what's on it. This just happens to be our ultrasound idea system board. Our MR techs came up with this idea system, and they get rewarded. You actually have to put down ideas. We have a bright yellow bulb. It means you've had a great idea. It goes in. It's not anonymous. We don't want these anonymous. We want everyone to know who's coming up with ideas. Everyone's idea counts. However great or however dumb it might seem, every idea is good and is listened to and is responded, and the techs get together with the radiologists, and we celebrate. We have a monthly award for the best idea, and the one agreement we do have is that every idea that's shared within a modality has to be shared with all other modalities if it leads to positive outcome. And here you can see we're giving this tech the bright idea, the bright spark idea for the month, and it's really been great for morale building, great for rewarding, for improving performance. The one challenge we do have is getting our radiologists involved. I think all of us struggle with that. The techs are very good at this. The nurses are great with it. The residents have come up with their own idea system, which works very well. The radiologists tend to still look down on us a little bit, and so our goal for this particularly is to make sure that we have radiologists involved in every modality system from every section so that they can start working more closely, and I think, again, that's an admission on my part that it's not as good as it could be, but it's a great opportunity for us to work on. Medical cue is another big area in LEAN, lots of them all over departments. You know, you can see I'm finding errors with a lot of these, and I just took my camera last week and I was finding these things going on in my department. Please inform the tech if you think you might be pregnant before your X-ray. The average patient does not think a CT or an IR procedure is an X-ray, so be very specific about what your signs are saying and what they do. Don't read it, but this is another way of standardizing work. These are checklists for the pregnant patient. A standard timeout script, really, for reading the timeout if you've got one person, two, or more than three people in the room. These are all ways of mistake-proving and minimizing variation. Another example of standardized work is a structured report. We came up with what we thought was a great structured report for pancreatic tumors. It's totally different to what our customers wanted. A surgeon sat down with us and came up with a totally different report. We should have got their feedback initially. This minimizes variation. It's great for customer service. It's safe. It's more timely. We're consistent in our reports. We're reducing errors in the actual reporting. Our radiologists are happy. It's much easier to get these reports out, and, of course, there's a happier surgeon, which is really the goal of this. Think of thyroid nodules, the amount of variation every time we see a thyroid nodule. Is it a spongy nodule? Does it, what are our criteria for biopsy? Think of the variation interpretations of thyroids, the variations in impression. We're doing a PQI project now looking at the immense variation in impressions of thyroid nodules and lack of an adherence to standard guidelines for biopsy, a wonderful opportunity for minimizing variation. Consider the added value you could add to your physicians. Dashboards, another very visual tool in the lean world. In this dashboard, this is the dashboard we have for unread and unsigned reports. You can see our MSK group has a large number of unsigned reports, which might be great. It might simply reflect the number of cases that they have and that they're struggling to keep up, and if I was acting on this appropriately, I'd go and see why it is are they taking a long time. Maybe we need to hire more people. Maybe there's a problem with the actual transcription of the voice recognition system. Reports are only as good as how you design them. This is simply a process report at one time. I might have downloaded this image off the web at 7 o'clock in the morning. They hadn't had a chance to sign these. This might have been done before we implemented voice recognition. So just understand, this is simply a process dashboard, and it's only as good as the person who's managing it. This is waste. There's a lot of cases sitting unread, a lot of cases sitting unreported. This is waste. We need to get rid of waste. I can walk around the department any day and see examples of waste. Mail, white coats, signs that really don't make too much sense to any of us. Here's an ultrasound ergonomic probe. The ultrasound techs have done their own PQI projects as reducing variation in their scanning so they can reduce ergonomic injury. That's waste. Excess scanning with your wrist is actually waste. So how else can we eliminate waste? Lots of different ways of eliminating waste. Any step or process that doesn't add value should be considered waste. There are lots of different categories of waste. Unused talent, waiting, inventory, transport, defects, motion. You can read for yourself. And I just thought of a couple of common examples. Unused talent, a radiologist putting in a PICC line would be considered waste. Maybe that person is far too trained to be putting in that PICC line. Think of how much time we spend waiting for images to be acquired, for transport to bring patients down, images to come onto PACS, inventory, transporting, defects in PACS, waiting for PACS, PACS has crashed, waiting for software upgrades, any number of examples of waste in the workplace. And you can pick any of these as PQI projects. Let's look beyond, Kate. How are these white coats adding value? These all sit there. No one seems to wear them. I'm paying for these to be laundered every two weeks. Do we need so many white coats? Who is wearing white coats? Is this adding value? How do we quantify value in the workplace? Well, we use a value stream map. There's some excellent exhibits I would refer you to in the quality storyboard section on the use of the value stream map. It's simply a way of quantifying the steps in the flow or process. Start at the beginning and go back. If you're frustrated in CT or ultrasound or IR because the patient's not there or there's holdups, go back. Start at the very beginning and see what's going on. Map out the process from the customer's perspective. Quantify if you can. See where the bottlenecks are and manage them appropriately. Take one at a time. Eliminate it. Get rid of anything that doesn't add value, but don't exclude your customers in the process. I downloaded this. A great study by Joey Steele is where they looked at a value stream in thyroid ultrasound, and it doesn't matter what the data is, but a very good example of what happens to a patient from scheduling a study, checking in, having a procedure, and they found five examples of bottlenecks. They focused on each of these. They eliminated these bottlenecks, and they've dramatically improved their turnover of patients and throughput in an ultrasound section. We all get frustrated with thyroid biopsies, but Joey actually stopped talking, and he actually is walking the walk, and they've improved their throughput. Very simple use of value stream mapping, and that's what they did. Again, simply doing the procedure is not the end. Of course, now it's improving flow, getting the result, getting the result back to doctor, and managing the patient. This is the value stream that we all deal with every day. The doctor wants to order a study, schedules it, patient comes in, you obtain the study. This is the standard value stream of a patient undergoing any generic study all the way to getting their treatment at the very end. There are a million ways of measuring it, and I just randomly looked through the literature at some of the metrics now for turnaround time. It's ridiculous. There are so many over here. What is that one important metric for turnaround time? Some people are looking at idle bed time. Some people are looking at the patient perspective. Some people are looking at dictaphone downtime, the amount of time that your dictaphones are not being used is waste. This is all really taking it to the nth degree, but these are the gazillion different metrics that people can sometimes use. Don't ever forget about satisfaction metrics. Ultimately, it doesn't matter what we're doing. If the patient or referring doc is not satisfied with the Value you're providing, you really need to make a change. We're going to get on in two talks' time, paul's going to be Talking on 5s workflow design. Suffice it to say, very Important, it's really being embraced by the japanese Philosophy and culture of improving flow within the Workplace. The 5s simply refers to sorting Things, setting specific locations, scrubbing, sweeping, Keeping everything clean, standardizing what you do and Sustaining these changes. This is the so-called 5s design That paul will get into in more detail. Lean architecture is what paul is going to be using. A lot of hospital architects are lean, again, from the Patient's perspective. Using software packages to Design the workplace that's aesthetic to the patient, Pleasing, ergonomic. But, again, we can't decide What we think is appropriate. We need to know how we compare This and what our patients want. How do we compare? We use benchmarking. Benchmarking is another lean Tool. You compare the nature, quality And service with a valid competitor. There are lots of things that we could benchmark over here. Peer review, fantastic opportunity. Here's my own peer review data. I'm happy to share it. It should be public knowledge. I seem to fall within the National statistics, which is good for this month. Again, i should be peer reviewing myself to my peer in My city, my medical school at the national level. If i'm not matching up to my colleagues, i need to look why And see what i can do to improve. That's another way of Benchmarking and trying to show improvement. What am i being benchmarked against? Maybe i shouldn't be benchmarking against my own Colleagues. Maybe i should be benchmarking Against those experts in the country that really are top in The field and i can try to improve my own performance. What is being benchmarked? peer review is a good example. Who manages the gaps? who's telling me i need to Pick up my diagnostic or interventional skills in ct of The liver? are these gaps being Effectively managed? these are lean type questions Aimed at improving performance. We're going to end up with four Slides, the standard lean management tools. This is an overview talk. What are these tools? I've shown you some dashboards. I've shown you the value stream. I'm going to illustrate the score card, the a3 sheet and The matrix. A lot of departments are using These from a management perspective. This is the ocean matrix. What is it? Suffice to say all it is is a way of visually documenting What it is you're trying to do, what your improvement effort is, Where you are on the journey, how far you've gone towards your Annual goals, how you're doing it, what are the tools you're Using, what your data is and who is doing it. This is a simple way of doing it and we assign people to each of These projects. It's one way of having a Visual manifestation of a project. We have a ocean in every one of our modality with the annual Projects and they know where you're going. If you're choosing the wrong project, this is all immaterial. Choose the right projects and use any tool to document it. Balance score card. This is a method that links Strategy to what you're doing. It's a tool that shows your Financial, your customer service, your operational goals And your staff metrics and targets. Very visual. A lot of people are using the Balance score cards. We use these on an Individual basis for the radiologist. It also allows you to translate strategy into your objectives That drive performance. It's interesting. We all have to have a departmental strategy. We compare it within different departments. When i ask people what their strategies are, they get very, Very confused. Don't read the information on This. This is simply an example of a Radiology strategy match. We have perspectives, Financial, customer service, operations and people. We have a mission. We have our actual mission Statement for financial goals, mission statement for customer Service. Then we define annual targets For each of these. This is an example of a Balance score card. How do we quantify it? This is how we quantify it. We'll take each of these same Domains, financial, operations, growth. We'll have a vision statement and list our objectives, metrics, Targets and initiatives. This is one way of visually Documenting a balance score card. Again, a balance score card is just one lean management tool. This is the one i prefer. Our residents all like using this. This is the a3 lean approach. I think this to me would be Ideal for pqi projects. You can plan your project, do And study it. If you look at it, what is the Reason that you're undertaking a specific project now? Why now? what is the problem now? What's driving you crazy? who complained about something? What is the current condition? what is the data today? What measures are you going to use to show that you have Actually introduced improvement? what analytic technique? When you did a root cause analysis, we've got jim Rawson, one of the co-organizers talking today. Jim is a genius at root cause analysis. He ran a course last year on it. Very, very important. We all need to know how to do effective root cause analysis. Find out what's contributing to the problem. Set where you want to go. What is your target condition? And then start putting plans in step, counter measures to Achieve your goals. Monitor your results and Standardize and disseminate. This is the a3 lean approach. I find it very, very helpful for anything, any little project. Our residents are all using this for their pqi projects. Any one of these small projects is also called a kaizen event. I'm using it because it is one of the questions here. What is it? it's applying scientific Method to standardize work processes and to humanize the Workplace and eliminate waste. So in summary, what is lean? I've given you a very rapid overview of the broad focus on Lean. It really is an unrelenting Focus on customer value, a philosophy of continuous Incremental small steps, using appropriate simple tools to Reduce variation. None of the tools i've shown you Are complex at all and you're all probably using them in Different ways, shape and form. Focusing on adding value at Whatever you do. If it's not providing value, See how you can get rid of it. Try to get rid of waste in all That you do and open up your blinkers to what the different Definitions of waste are. Respect everyone in the Workplace, including the patient, in terms of how they Are going to see this as providing value. Take the long-term view. Don't go home and say i'm Going to implement a lean process. Everything you do can be lean. It's small steps at a time and It takes a while. I'm going to talk a little bit about lean in daily work or Lean in daily practice. At the university of michigan, We have chosen to include lean in part of our overall health System strategy or what we call our michigan quality system. I'm going to talk a little bit about what that is very briefly. I'm going to take you through a model and an example of lean in Daily work and how in the workplace, getting people Involved is not just a process, it's not just a method, but it's Also a way of improving the culture of the way people Interact, of minimizing blame and improving relationships so That when you move from one project to the next process Improvement project, you're establishing an increasing Foundation of trust and respect and the value that people see And the different parts that they bring to what they do in a Very complex health system, department, or specific area of The radiology department in which they operate. So our quality system at the university of michigan, we call The michigan quality system. It's founded on many of the lean Principles such as just-in-time delivery and building things in First-time quality. It reflects our underlying Health system values of respect, compassion, trust, Integrity, collaboration, and leadership. It includes things like using the fewest resources to Consistently deliver exactly what the customer needs when the Customer wants it. And in terms of quality, it's About being error-free. It's about not making, Accepting, or sending on an error downstream which will only Magnify the effect. We try and do things like Leveling the workflow, we employ constant continuous Improvement in pdca cycles, and we try and develop standardized Workflow processes. So it's not about the person And what they bring in terms of they succeeded or didn't Succeed, but it's how the system operates so that minimizes Blaming human beings. Overall, this makes value in The flow of our health care by eliminating errors and waste and Depersonalizing the approach. So it's using, as jonathan has Talked about, the fewest resources to consistently Deliver appropriate care. How many times does somebody Identify a problem and say, if only i had more a, more people, More imaging equipment, more staff, i could do better. But if we look back at our systems and we think about all The steps along the way of something that we're trying to Accomplish, you will inevitably find waste that if you can Eliminate, you might be able to do more with actually less Instead of the first thing out of the gate always being i need A new system, i need a new staff member, i need more resources. So it's all to try and deliver the right care at the right time In the right setting for the patients, and increasingly we're Including visitors, patients, and family members in the lean Process improvements that we're using so that we have a patient Family centered care approach to lean as well. It's not just about what we're doing, but it's including our Patients in the process. So i'm going to talk about an Example of lean and daily work through our general imaging area Of our inpatient facility, our main hospital. And i'd like to compliment the staff in our area, cindy Paterno is our general imaging manager, tony taylor is our Clerical manager, t.C. Thornton is one of our general imaging Supervisors, jerry will is our head administrator over general Imaging department, and susan fisher is our embedded internal Lean coach in our department. So this involved many areas of The department to look at our radiology inpatient general Imaging area. And the route for the process, Why do we choose to look at general imaging and apply lean, I think increasingly you're seeing hospitals try and look at Any source of waste and delay in length of stay, and the role That radiology might play is very central to inpatient care Today. And if we're delaying a step In diagnosis, which means a decision to be then made for Treatment purposes or discharge purposes, then we're adding Waste to the system. So hospital leadership Approaches and said we'd like to look at how general imaging, And we've done this with ct and mri as well, but general Imaging, how are we impacting ultimately for them was length Of stay. What we wanted to focus on is The component that we can control, which is from the time The exam is ordered to the time the exam is completed, and that Was the focus of our general x-ray staff. So we put together a lean implementation team, we call it An lit in the hospital x-ray area, as the first place in our Department several years ago, hoping that what we learned Through this process would spill over into other areas of the Department and foster the further outreach and development Of lean processes. At the time, this was about 2009, general imaging had fairly low morale among the staff. They felt that they were being blamed or scapegoated as an area Of the hospital that was impacting length of stay, they Didn't have any way to respond effectively, didn't have any data On which to base it, and we thought that using a lean Process might not only improve the operation, but improve the Interpersonal relationships and morale. So we started training the lead management staff in the general Imaging area in lean processes, and then they trained a few more People just underneath them in the operation who trained the Trainers, both the technologists and the clerical staff members, Which is about a six-hour lean course that's run in our health Program, and then they in turn trained every tech and clerical Staff in our inpatient general imaging area in about two-hour Sessions in small groups to make sure they understood what lean Was, what the tools were, the goals of why we were doing this, How we were going to generate the value stream maps that Jonathan talked about before we started the go live for this Particular process. One of the things we tried to Do is lean is not just about putting metrics on a bulletin Board and hoping you have a good outcome, but waste affects Everybody in the health system, and it affects every staff Member, and we tried to also approach the personal side of What lean means in relationships. Waste causes physical fatigue. You're doing more work and Spending more energy than you need to accomplish a task by Putting band-aids on things and short-term fixes. It causes emotional frustration, stress. It makes people do this and blame others. How many times might we hear in a hospital system, it wasn't Radiology's fault that the x-ray or the ct or the mr didn't get Done on time. It was transportation. It was nursing on the inpatient floor. It's a constant blame some other component, and it ultimately Steals your time. So we wanted to use lean not Just as a process improvement tool but as a relationship and Relationship improvement tool. In a traditional team structure, In a traditional hierarchical system, we think about a leader At the top of the pyramid, and we think about the people doing The work on the floor is almost at the bottom of the pyramid, And leadership is often looked at as kind of the ultimate Pinnacle. It's customers and employees Primary duties are to carry out the wants and needs of Operational management, the traditional boss employee Structure with relatively little input from employees on how Operations can be improved. How silly is that in a large Operation when the people who are actually doing the work and Have the hands-on and have the most knowledge are the people At the bottom of the pyramid in a traditional system. So what lean does is it flips that. So the leader, instead of being telling people what to do, the Leader's role is to support people to do process improvement And accomplish goals collectively. So it inverts the pyramid completely. It's leadership supporting the team members. It's the concept of servant leadership, that is, leaders Developing the capacity to support other people to identify How to improve processes. So it's a little bit of a flip And a culture change both for leadership to understand how to Function this role as well as the people with boots on the Ground feeling that now they can actually speak up and they Can actually provide feedback and it will actually be taken Seriously. One of the things that we use Lean for is to help create a fear-free environment. So, again, it's not just about processes and stream maps and Output data. Fear in lean, it makes people Feel defensive. It keeps issues submerged for Years when they don't feel they can actually speak up and be Heard. It creates a crisis orientation Where you only get to problems when some really big thing Happens, like some vip gets admitted to the hospital and Their x-ray was delayed for six hours and everybody comes Screaming, why did that happen? why did that happen? So it's the idea of using lean to create information to drive Improvement and not to pass judgment. It's not about blame. It's using data to uncover what The issues are and letting people bring them forth in a Blame-free manner. So we used lean in our daily Work elements as part of doing our process improvements in our General x-ray area. And we implemented several of The lean tools that have been mentioned already. We use daily team huddles. We actually do these on every Shift in the general x-ray area. And when we started talking About having daily huddles, which is basically gathering Everybody together for just five minutes on each shift at one Time, they said, we can't do that. We're too busy doing x-rays. We're too busy taking phone Calls. We're too busy in meetings. We can't find five minutes to meet. And this is the traditional response to the concept of Having daily huddles is we can't because. But five minutes in a daily huddle where everybody in the Area is standing around, everybody can see each other, Who's here today, how's the equipment working, did anybody Call in sick, were there any problems left over from the Night before, who went out of their way to do a great job and Hand out compliments is a really great way of building teams and Bringing solutions forward. We use something called daily Problem solving through the everyday lean idea or the e-live Process, which i'll mention in a little bit. We use daily and weekly leadership walks as part of the Process improvement, and we have a health system manner for Documenting how lean improvements work in our own System called confluence so what we learn in one area of the Hospital can be shared in other areas of the hospital and health System. It was important that we identify Metrics that were important to this particular area. And important to the particular question that we were asking. So it would not be fair to ask the general x-ray area to look At length of stay because there's so many other things That contribute to that, but we tried to look at what they can Control, the small measurement from the exam order to the time The x-ray tax completed the exam. An ideal metric is best measured in small increments so that it's Real time. It doesn't require intense Painstaking review in order to measure. They can be quite simple. They connect directly to what The customers tell us they value. It connects directly to our priorities as a department and Institution, but yet it's high level enough when summarized so We can show it to leadership and the value can be recognized. And these good metrics allow us to surface many different Problems and to compare them relative to each other. So a very important part about lean and daily work is the People doing the work need to set their own goals. I can say i want every x-ray done as soon as possible as a Leader at the top of a hierarchy, but that's really not Realistic to expect that everything is going to be done Two or three minutes after it was ordered. The people who are in the operation set the value. So our general imaging technologist set a goal for Inpatient general x-rays that 80 of the patients would have Their study completed within 20 minutes of the scheduled Appointment time. Remember, these are inpatients, There are many issues, there are sick patients, there are Coordinating care across the health system, there's Medications they need, there's transportation issues, so they Set a personal system goal of 80 of studies completed within 20 Minutes of the time they were scheduled. And then the clerical staff in the x-ray area set their own Goals. 95 of the patients would be Booked into the ris system within 15 minutes of getting the Electronic medical record order, and they have peaks and troughs That they didn't completely understand, but they felt were There, and they wanted 90 of the stat and urgent portable exams Scheduled within 15 minutes of the order being received so it Could be completed in a timely manner. We used the value metric board in general x-ray, so we didn't Use big computer spreadsheet type data. We wanted to make this meaningful in the workplace, so This is just a big dry erase board, and you can see on it, it Has every day of the week, and for each day of the week, you'll See, and this is a one-month calendar, and you can see there's Three different color bars on each of these boxes. Each one represents a shift of the day, and they got to choose Their own visual display, so when they were doing really well And they hit their targets, they had a green. It's general x-ray, so they like the bones and the fracture Components, so they've got a nice clean bone, no breaks, they Met their target, it was green, so you can see where all the Green is very quickly visually. Then for yellow, they maybe Weren't performing quite as well, kind of your slowdown, What's going on, maybe take a look, it's kind of an Incomplete fracture, and then for something's broken on the Shift, they used a complete fracture. So these are of their choice, and these are some of the fun Elements that they can come up with to help make lean enjoyable In the workplace, so you can quickly look at this, and you Can see where the problems are in a very quick visual way, and Then they report numbers of cases that they did on each Shift, and how many were completed within the goal, and How many weren't, so they keep track during each shift Themselves, they post the numbers on the board, and they Give themselves a visual cue, and you can look and see are There trends very quickly by shift, is it the first shift by Looking horizontally, is it particular days of the week, Where are the system issues happening, and then they can Make notes as to when there are specific problems. In our clerical area, they also had their own lean and daily Work value metric board, and they got to choose their own Icons, and i always have to laugh at this one, they have the Same model of using several shifts a day based on the way They work, and the time and the shift hours that they work, they Use color coding, so they set their own visual metrics and Their own process improvement plan, so making it local. So we started to collect data, and we collected historical Data, we put in place process improvements based on their Suggestions, based on their value stream map of where the Bottlenecks were occurring, and we showed them data on how they Were doing. So we looked at before they Implemented, and then after they implemented, we set their goal, Which was the 80 percent of exams completed within 20 Minutes of the scheduled appointment time, we gave them Data on each shift and their overall performance. And while they were performing reasonably well on most shifts, You can see early on there was heterogeneity, so you wouldn't Want to focus your process improvements in the shifts that Were working as well, you want to focus in the area which is The deficit, the area you're not making your target. And as they moved up in that area, the same processes that Improved their function in that area also improved their Processes in other areas, because they carried over Systematically. They tracked with their little Notes, and they calculated the reasons for delays, why could They meet their goals within 20 minutes of a scheduled Appointment. Again, this doesn't have to be Some big computer spreadsheet with some lean coaches sitting There tracking data that comes out of complex computer systems, These were just notes they kept on their visual metric board. Did the transporters arrive early? Did the transporters arrive late? Was it a long exam, a difficult patient? Did they have to verify the order to know it was correct? Was there an equipment or computer issue? Were they waiting on a doctor to come and assist, maybe a Flexion extension cervical spine exam? Was it a SWAT patient where the icu team has to come down? Was there a problem getting into the room or room access issues? Well, they had always felt it was transporters being late. When you're just complaining about something, it's just Noise. Oh, it's always the transporters. It's just always the transporters. We can't do our job because it's someplace else. But if you put it into data, they then took this to the folks Who run the transportation for the health system, and now it Wasn't just we're complaining, we're showing you. We're not blaming you. We're showing you where our Problems are in completing a goal which is aligned with Health system goals. It's we're having problems with Transportation. So they were able to use this Information to then go and work with other department Transportation to try and fix this bump in the road. The clerical staff looked at how they were doing, and they looked At it over shifts again, and they tried to identify the Blockages, the problems, the obstacles. Some of the reasons for the detailed delays in patients Coming to the department, the big ones were the schedule was Busy. Turned out that that was actually An it system issue, and it really wasn't that the schedule Was busy when they drilled down to it. That the swat teams were busy. We couldn't get enough staff Support from the icu side to bring people down. That there are busy issues on the floor with nursing staff or Patients not available. Or that the er staff were too Busy to answer the questions. So tracking the delays, both on The clerical side and the technical side, helped us Identify ways to have process improvements. Now, the team huddles have been a great success, and they meet At the visual metric board once per shift. They review the board to look at the value metric status and how It's been working. They document any problems, any Waste, things standing in the way of them meeting their goals. If they have an idea, they submit what we call an eli Form that's initiated by the team member who identified it, And owned by them or somebody else who takes responsibility And then reports back on the process. And for small things, they're able to just act on them Quickly. For bigger things, they need To go up the chain, which is why it's important to include the Leadership and the gamble walks and the leadership huddles. But we always try and close the loop back to make sure that Every idea is addressed. We also include concepts of Service excellence and customer service in the huddles as a Regular reminder of what we're here for. So here's just an example of an eli. They wanted a blanket warmer. So what was their problem? Many inpatients are requesting warm blankets when they're Getting their x-rays. Currently, the closest blanket Warmers are located either in the emergency department or way Down the hall in the radiology and patient holding area. And every time a patient asks for a warm blanket, the staff Have to leave their area, leave the patient, find somebody to Watch the patient, walk to a different area, spend time, Waste to come back to get the patient a blanket, which does What? it delays the next patient Coming into the system, and it compounds itself. So we want them not only to describe the problem. We want it to be precise. No blanket warmer in their area. And if the patient wants a blanket, they have to walk someplace else to get it. And the impact of that problem, the waste, is the time to walk to get the blanket, creates delays for the next patient, impacts transportation schedule, and reduces both their satisfaction and the patient's satisfaction. We also include the name of the person who reported the problem and the date it was reported and the date it was resolved. So somebody had an idea. I mean, this is just a simple example. Get a blanket warmer for inpatient X-ray. Well, if a tech just came and said, let's get a blanket warmer, we'd have no reason. Why would we do it? We say, oh, just walk down the hallway. Walk to the ED. But when they come to it with a systematic reason and knowing the impact that they can have on the system, then it becomes a better conversation. It's not just asking for resource. It's asking for resource to make a difference. It's not a very expensive resource. So they implemented it. We didn't have to go all the way up the line to department leadership to do this. This was an ELI that they could manage at their level and could act on. And they got a blanket warmer and they found a place to put it. And they're happier and the patients are happier. And we don't have as many delays in transportation, having to wait for patients to get a blanket. So it has many system-level impacts. Just a small idea. And many small ideas have many system-level impacts. We do leadership GEMBA walks in the general imaging area. And we've been doing these in this particular area for four years now. We have the general imaging manager and the clerical manager visit every day to the visual metric board and the supervisor on every shift. Our administrative manager for general imaging visits weekly. And our chief department associate administrator and myself, we visit monthly to constantly reinforce the value that we see in what they're doing and the process improvements that are making. And occasionally we show up unexpectedly in a daily huddle. And we map out our GEMBA walks and we actually mapped out who's supposed to do what. Because as you're learning, you need to be pretty precise so that people are informed and people understand what to expect. The idea of leadership dropping in on people, as Jonathan said, is they get fearful. Like, why are they here? What are they watching me for? So we mapped out physically where we wanted to walk, what we wanted to observe on the map of the department. We told the leadership doing the walks, we want you to review the visual metric board. We want you to review the ELIs that are submitted. We want you to talk with at least one patient. We want you to talk with individual members of the team and learn about their problems, encourage using the processes, provide feedback. And we want to repeat these every time you come through in your GEMBA walks. So we show this not only to the leaders who were doing the walking, but we also show this to the staff so they know what to expect and why. So some other examples of how lean and daily work has helped and some of the outcomes that we've been able to see by using lean and daily work. One thing we looked at was our radiology call center. And this was going back about five years ago we started the process. We wanted to decrease the time on hold, decrease the times on the call, stop transferred calling happening where people were delayed and stop drop calls. And we started to have metrics, which we never had before. And some of the things that came out of that process were cross-training all the staff to handle every modality before they were handling only one. We established one phone number with a single phone tree instead of six different call in numbers. We streamlined and standardized processes across them that they developed and learned with each other. We implemented a call quality and monitoring program because once you have metrics, then you can monitor to them and measure to them. They implemented employee recognition and rewards program and they added FTEs to meet specific metric goals that were defined out of what they developed, not just saying, oh, we think we need somebody and we're overworked. We've done this for our stroke arrival process to decrease door to needle time for stroke patients. We've used this to look at the impact of resident workflow and productivity. We've used this to standardize the reporting of test results in specific situations that are urgent. And you'll notice every one of these has a team of people that crosses many areas. We've used this to prevent retained surgical items in the operating room and the role of radiology in this process as a system level. But ultimately what all of this does, and these are some pictures from one of our annual quality storyboard days, is it improves communication amongst people. It depersonalizes process improvement so it's no longer about blame and it's more about engagement. And when you have more engaged people, it's really palpable. And when they start to show that to other areas that are outside radiology, radiology can be the nidus of process improvement for areas that you wouldn't even begin to imagine and that people will see how well radiology can do this as an area that touches an entire health system and can really make a difference. So that's a little bit about Lean in our daily practice using x-ray as one example and showing you other examples of how we've used Lean to improve our processes. And ultimately, it's about improving relationships as well as improving the metrics by which we operate every day. My name's Paul Conactus. I'm a radiologist at the Medical College of Wisconsin. Today I'll be talking about Lean process improvement methods for radiology workplace design. I'm glad to have this topic because it uses some very simple tools to be extremely effective. I always like to think of a well-defined workplace as actually luxurious. Efficiency is a necessity for our survival in the current economic situation, but it actually feels good to work in an efficient situation, so I always appreciate that. So, one is we'll talk about some of the, just a brief review of the central tenets of Lean just for a little context. Then after that, there are two central tools for designing the workplace. One is 5S and two is spaghetti diagramming. These are two very powerful and simple tools. Okay, central tenets of Lean. In manufacturing, where the Lean processes were developed, specifically in the Toyota process center, value added is simply described as anything the customer is willing to pay for, i.e. the final product. Waste is anything that broadly does not add value to the process. So, when I'm at my workstation, if you look at how I add value to the overall process, rendering accurate, timely diagnosis and reports that are actionable, that's a big part of how I add value as a physician. Waste is any distraction that does not contribute to patient care. That's a, it's a good general rule. For imaging machines, the timely generation of images and diagnostic image, the timely generation of not only images, but diagnostic images, it's a very simplistic way of looking at how you can use your machines, but waste is any underutilization of equipment or generation of non-diagnostic images. Once again, an oversimplification, but a good place to start. Kind of reminds me of something one of my chief residents taught me before I started my first call. He said, if you're not looking at images and there isn't, or there isn't betadine on your fingers, you're probably falling behind. Okay, so, intelligent workplace design. We specifically, when we're looking at the eight wastes, the two big wastes that we're looking at are transportation waste and motion waste when we're doing workplace design. So, there are two deceptively simple tools that are often used to do workplace design. One is called 5S, and the other is called spaghetti diagramming. Now, the 5S methodology was originally developed by Hiroyuki Hirano in Japan. He's actually, you can buy his books on Amazon. I looked that up, and I will not attempt to mispronounce the Japanese words, but it roughly translates into sorting, straightening, sweeping, standardizing, and sustaining. It's a simple process that helps you maintain a rational workspace on a day-to-day basis. So, where can you start? Where can I start to learn Lean without investing a huge amount of time and money, and without having to try and convince other people? As Dr. Kruskal stated, it is a process to get Lean into your culture. I find that my workstations are a great place to look at this. So, we have two workstations. Now, a lot of you are looking at the workstations and evaluating them as a compare and contrast, but obviously, the biggest problem is there's no radiologist at either of them. So, this is a workplace exercise that you, once again, that you can do on your own and start to learn these processes on a daily basis. So, first thing, you want to eliminate all unnecessary, redundant papers and equipment. This workstation, I have no idea where these guidelines came from, when they were sorted, and when they were pinned up, and they were certainly not standardized. So, the first thing you'd want to do is eliminate a lot of the waste. Additional food and other things may not be necessary in the area. The next thing you want to do is maintain the same physical layout from day to day at the workstation. My value added is my eyes on the images and my accurate diagnosis of reports and getting that information to my clinicians. If I'm searching around my workstation for five minutes or having to reset my workstation for 10 minutes every morning, depending on what you're reading, that's one to five studies. In 5S methodology, the idea of straightening, this idea of a place for everything and everything in its place. A good example is a master craftsman. We have a piano in our house and we have it tuned once a year. My piano tuner spends about five minutes tuning the piano, but he spends about the same amount of time carefully laying out all of his tuning forks and other things. A carefully arranged workspace can make a lot of things go a lot better. A term called shadowing, where you actually have outlines on the workspace where things should go, probably not necessary at a workstation, but can be very helpful when you're setting up interventional procedure trays. Keeping things uncluttered and organized. Sweeping. Standardizing. If you have a consistent standardized workstation, you can simply, if one workstation goes down, you can simply go to another. So let's just take a look at these two and compare them. So this is obviously a cluttered work area, and you can see that things are arranged in a way that don't really help with motion economy, as opposed to here, where things are arranged, now obviously for a right-hander, in an arc in the amount of time they're being used. In addition, what we found is relatively cheap and an easier thing to standardize. We use these little flip charts for things that are routinely looked up. Phone numbers, policies, other things. That way, not only is it can be looked up very quickly and it's way cheaper than a monitor, but we can keep an eye on them and keep them standardized so we don't have like 14 different phone lists in the room. So the last thing is sustaining. It's a constant ongoing process, not something that should just be carried out before inspections. So when you're setting up a workstation, you often want to use the principles of motion economy. An idea is you want to have things arranged in a horizontal arc below shoulder level. That's a very natural way for your arms to work. It says you aren't gonna get repetitive stress injuries if you're working at that level. The other thing is visual management. In your workspace, the things that you use commonly should pretty much be within your peripheral vision. An easy way to test how far that arc is, as I just put my elbows at my side and I go out till my hands disappear. I can't see my hands anymore. Odds are that's not an efficient place in the workspace. Also, other things to do, as Dr. Kruskal touched on, adjustable workstations. You can really reduce fatigue and repetitive use injuries. Ergonomics and efficiency can go hand in hand. The other thing is you always want the items in a work area, regardless of what it is, to be in front of the user as much as possible. Obviously, sterile procedure or concerns about radiation exposure can cause problems with this. And the other interesting thing is people work pretty much better in an arc associated with their dominant hand. Things I use a lot are right by my right hand. Things that I don't use are by my left hand. I'm right-handed. It's funny, but it really makes a difference how quickly you can get to things without taking your eyes off the images. Less than five feet from the user. Once things get to be five feet from the user, they often might as well not be on the workstation. You can put them in another area. And the other thing is relieve your hands of as many tasks as possible. It seems to be a lesson that we knew back in the days of film and then in the early days of PAX forgot. You know, the foot pedals disappeared. A lot of the more ergonomic chairs that worked with the film disappeared. So it's actually more of this relearning what we already knew. And then another thing is maximizing eyes on images time. My hands generally don't come off my dictaphone and my mouse when I'm dictating a report till the very end. I actually use a gamer mouse, you know, like the people use when they're playing Halo or something online. It has multiple buttons on it. It's great. I actually didn't do that until this year until one of my fellows who came from another program pointed out, why do we have to keep on looking down and pressing the button D to get the measurement to come up? That's ridiculous. So keeping your ears open to people from other areas can really make a difference. It seemed like a minor change but it's been actually dramatic improvement. So the concept on this was actually designed originally for fighter pilots. It's called HOTAS, hands-on throttle and stick. Fighter pilots in a well-designed airplane are often looking through a heads-up display, which can be equivalent to our monitors, and they have their hands on their throttle and their stick and all their most commonly used functions are there. It's great. It's great when you're a fighter pilot because looking down into the cockpit can be a real problem. Say, if you're in a tight maneuver or trying to land or someone's shooting at you. The good news is a lot of this stuff, well, it was designed for the Air Force. Actually, you can see it in gamers. Online gamers have similar setups with their PCs and it makes a big difference on a day-to-day basis. The principles of motion economy complement the principles of ergonomics. Well, I don't have the time to fully discuss ergonomics. It is important to note that up to 38% of radiologists have had a prior diagnosis of repetitive stress syndrome. So paying attention to ergonomics in your workplace, at your workstation where you're there multiple hours a day makes a big difference. Okay, so we're gonna now branch out into the larger workplace. Since we've already looked at how we can change our immediate workplace, how can we change on a more macro level? Once again, we're gonna try and reduce transportation and motion waste into eight waste when we're designing intelligent workspace design. A great way to look at the efficiency or inefficiency of a system is to use something called a spaghetti map. It's gonna get pretty clear pretty quickly why it's called a spaghetti map when I put this out there. Now, these are simple hand-drawn maps that demonstrate the motions necessary to complete a process. And the more that your process starts to look like a bowl of spaghetti, the more inefficient that process is. So it's kind of funny. Things that before you map them that seem totally rational can actually turn out to be pretty bad. Here's a portion of our reading room. This is the area where we read body CTs. And I'm just gonna map out one process. We used to have paper requisitions before we went paperless. So if I wanted to pull a CT, especially if we were totally caught up, every CT I'd stand up, walk over, and come back. That actually looks like a pretty smooth arc. Until you look at how many other people had to do the same thing. Say I'm gonna get, say we're gonna be very ambitious that morning and maybe read two CTs. Or maybe read three a piece. All of a sudden, this is actually starting to be a relatively wasteful process. So the idea is, when you map out a process, you want to reduce or shorten as many lines as possible. And what's funny was, we just went paperless. And the good news was, it's funny, you think this is a minor or common sense thing, I could probably read one to two more studies a day, easily, once we went paperless. And that was great. And the other thing is, no one got any DVTs. We still take breaks and walk around, but we don't have to stay locked in our area. So what about, since we are looking at processes, why don't we look at a work cell? A good idea with a spaghetti map is, A, when you're designing a work cell, it's good to have a spaghetti map so you can design it correctly. But B, even a well-designed work cell will not be efficient if you use that area inefficiently. So for example, here's an example of our fluoroscopy area. This is a central control area. We have a small reading room here. Then we have our fluoroscopy suites arranged in a ring around it, with a hallway for the patients and then another doorway for us. So this is a relatively well-designed area. But if you looked at the workflow we were using, where the radiologists performing the fluoroscopy procedures would be sitting in the small reading room and coming out, doing the procedure, and going back, coming out, doing the procedure, and going back, now we are using kind of a radial spoke design, but that's actually quite inefficient. So we did two simple interventions in the work area, very low cost, and were able to actually really reduce our motion. First thing we did is we introduced a central workstation. So instead of having to dictate here, it could also be here. The other thing is it could keep the team central. Instead of having your team in the corner of the room, you had the radiologists, techs, and everyone in one central area. Just gave people the tools to do their job. The next thing we did was we started arranging our workflow in a nice U shape. So each one of these lines just represents the flow of a single patient encounter. Where did my feet go? So you work in a nice, simple U shape in the series. Obviously, I'm not running the interventional area, so we skipped that. I would land about every three studies, dictate them, get those reports out to the clinics, and then keep going. So if you look at our initial workflow, where we were using kind of a radial hub type method into more of the proscribed U shape that most of Lean recommends, you can see that actually resulted in a greater than 50% reduction in distance traveled. Now, that may not seem like a big change, but when you have a metric of a 10-minute waiting time and you're routinely hitting 13 minutes, shaving three to four minutes off each study makes a big difference. Now, that would be an idealized workflow. In a more realistic workflow, sometimes the patients are late, sometimes the patients are sick, but still, you can see here, even with using a central area and then randomly going to rooms, you still have a 25% reduction in trips and a greater than 25% reduction in total distance traveled. So the nice thing about a U shape workflow is not only is it efficient, but what's nice is if you have a big surge in demand, instead of having one radiologist or resident moving from room to room, you can insert one here and you can insert one upstream, and you can continue to use that bottleneck of number of rooms to its maximum efficiency. The other thing is, once again, counterclockwise workflow works better for right-handed individuals. So using a Sperry diagram is very cheap and it's a very powerful tool. You can get your patient wait times down. The total cost of this was a couple emails to get the diagrams and then some pens. It was very quick, but let's look at how an appropriately designed workplace is designed. Designing things rationally, at first, the right time, also makes a big difference. It's not just how you interact with it, but if you're having a new area, if you map it out and then design it correctly, that makes a big difference. So a model that's often discussed is the onstage-offstage model. The onstage is anywhere the patients go. The halls, the first door into the exam rooms. Offstage is where you and your team are together, centrally located. So ideally, you'd like your patient care rooms in a semicircle or circle, and then a central common work area. The outer hallway should be a clean, quiet, soothing environment. Patients are scared. They don't need to be walking through a bunch of humming equipment and cooling equipment and other things. That does not add to the patient experience. If they're in a nice, well-lit hallway with art and other things, it makes a difference. So you have one door for the patients to come in, and then a second door for the common work area. You can see here we also have the patient waiting areas, and the patients can change and wait, and then come around to the rooms on the outside. The central work area, on the other hand, should also, actually is very good for your team. You keep, it facilitates communication to have everyone in the same central place. If you can see everyone on your team and talk to everyone on your team, that's great. You aren't segregating radiologists, technologists, and nurses. You're getting a much more flat-type management approach. The other thing is you'd like to have modular furniture. It's preferred to built-in furniture. You may have noticed that on my spaghetti maps, I was not crossing directly through this area. This is a large built-in cabinet that replaced the film processing unit. I mean, this thing is extremely difficult to, that'd be very difficult for us to remove. I can put in a requisition for it. But if you have, they actually sell office equipment that's modular, you can simply rearrange your workspace as needed. Okay? So then, finally, when you're designing a workspace, one of the key elements that you'd like to build in is visual communication. So, as you saw in Dr. Casaruni's talk, there was the whiteboard, which is a very effective and inexpensive solution. The other thing that often is used in our department is that we actually use large LCD monitors. I guess it kind of looks like a sports bar. What we're actually checking is study schedule, patient location, and study status. We placed one on the wall here, because it went by the central workstation. Obviously, it'd be nice to have it hanging in the middle like you would in a basketball stadium. Then, on our central workboard, we actually have the built-in work list throughout our health information system. And so, in a glance, I can tell, is the patient an outpatient or an inpatient? If it's green, they're in a room. If it's yellow, they're in the area and are gonna be on their way to a room. And then I can actually see the transport cart, too. So I know who's coming down and when. But more importantly, not only do I know it, everyone else on my team knows it, too. No one needs to tell me that our one o'clock appointment is gonna be 15 minutes late because they're still in transport. I take a look, I know that. The other nice thing is that we have on our whiteboard is we keep notes. So when we do our morning huddle, when we're running the board in the morning huddle, we actually will put the notes. If something's gonna deviate from our standard procedure, for example, in a fluoroscopy unit, we're gonna be using iso-osmolar contrast because they're aspiration risk. It is written directly on the board. So everyone knows at the beginning of the day when we run the board and as the day runs. It's kind of funny. I wish I had one of these in every room because I spend more time coming out, peeking out of rooms to figure out what's going on on the board than I do having to ask my lead tech who's coming. So once again, think of a scoreboard at a baseball stadium or even better if it were hanging centrally, a scoreboard at a basketball arena. So another nice thing is it really reduces your management burden to have good visual communication. Basically, everyone can become self-service. We're all on the same team. I don't have to tell people what to do or where to go as often and I don't have to be reminded by my technologist that you really need to be in room four now. I can look up, I know, they know. The other thing is it allows me to manage my time better. We have these worklists for pretty much every area, CT, MR, and the other thing that we also do in our electronic health record is I can actually even check the ER's track board. So I have a virtual shared whiteboard with every department. So then I can do things like answer email during a downtime or I can postpone my lunch break. I just saw that there was a multi-car accident. And so once again, this allows me to make decisions without needing to involve my management. Okay, so the conclusions are process improvement methods from other industries have been applied in various healthcare settings. The repetitive nature of many radiology processes lean themselves to the utilization of lean. Any single intervention may only save seconds or minutes, but the savings multiplied over thousands of studies can be significant. In addition, each small improvement can make a significant, can actually add up to a more and more significant aggregate impact. A nice thing about a neat, well-organized workspace is it improves our patients' and our clinicians' perception of our department. It also improves our morale. As one of my coworkers says, sure, you can drink champagne out of a paper cup, but it's a lot better out of a champagne glass. Appropriate motion economy increases efficiency and reduces injuries. And always try and compliment your physical workspace with a well-designed electronic workspace. These principles have been applied in the diagnostic setting but can have even greater impact in the interventional setting. And I'd just like to thank the whole team that works together to make all these things happen, because that's probably one of the most critical parts of making any of these things work, is having everyone involved.

Lean approach

radiology department

continuous improvement

eliminating waste

customer needs

team collaboration

process efficiency

visual metric boards

incremental changes

customer satisfaction

real-time feedback

leadership support