We're going to sort of concentrate on this portion of the Lean Healthcare System, and of course, in my slide, it's the foundation. I mean, some people could call it the basement, I would call it the foundation. It's an important part of improving what we do, and I'm going to try to step through the concepts a little bit of the terminology, I'm going to try not to get stuck on the terminology as you may already have learned from prior sessions. The terminology is very specific to Lean, and it's really the concepts that we want to understand more than the words. When we look at value, which is why it's called value stream mapping, we have to look at the service we provide to our customers, and there's a lot of business lingo in Lean, but our customers are typically our patients, sometimes referring physicians and others. We have to make sure that we have defined value by the customer and their needs and not our perceptions of what they need, which is why we often involve many, many people in the Lean process, including our patients. In general, the activities are defined as value add. Will the customer be willing to pay for it, or will the customer desire this? Or non-value add. Non-value add, you can equate to waste. Waste is bad, and in the unimproved state or a typical non-Lean state, that's about 90 to 95% of activity is wasted. Lean uses a relatively strict definition of value, and part of the reason for that is to have a goal or an objective. We know we can't hit 100%, but our goal should be 100%. So again, you have to have all three criteria meet. The customer has to be willing to pay for whatever you're providing. That may be many different facets. They may want to pay for expertise. They may want to pay for top-line equipment. They may want to pay for great parking. They may want to pay for great food. We can't assume exactly what the customer wants, even though we often assume that what they want is efficient, high-quality service. The value-add criteria includes those things that directly transform the way we do to improve. Directly transform refers to substantive changes that move us to our or towards our goal that are reproducible and long-lasting, and that's one of the downfalls that we've seen in industry and in healthcare applications, that these changes are meant to last. They can't be quick fixes. They have to be continuously monitored, so as our systems and needs change, that we change what we do. Obviously, we want to do things right the first time if possible, and that's part of the process. In the center of this is value. I'm actually no one who likes a Venn diagram. When I see a Venn diagram, I usually start to feel slightly nauseated, but as they say here, it tells us nothing but it is really cute. Waste is the next term, and again, I know you probably had part of this discussion earlier. We're talking about anything that isn't perceived by our customer or our patient as value, and that would include defects in what we do. We want to do it right the first time. Overproduction, we have wasted product that we can't use, at least not right now. Weighting, whether it's weighting of our patients, weighting of our clinicians, caregivers, weighting of our transport people, that is a significant source of waste in all of our systems. Neglect of human talent. Have we used people to their capacity? Are we triaging? Are we dividing the work appropriately? Transportation, how we move people, services, goods, information from one place to another. The motion that we have associated with inventory and patients, and the excess processing. Are we spending more time than we need to produce a product? We want delivery to be continuous, which is sort of the zen-like state that we can never achieve, but we want to try, so we look at our current state. The process of lean requires constantly questioning why we do things the way we do. It's an important question. On this, obviously, red is equal to waste or wasted time. Green is ideal value. What we would like to head toward is from a current state, which we're going to map out, and we're going to head by asking why and putting in solutions in place, to an ideal state which we will not reach, but really where we're heading is our future state. It's the best combination of achieving our goal in as efficient a way as possible, realizing that there are steps in our process that we can't get rid of. We want to decrease utilization of personnel and supplies. We want to pull and supply materials just as they're needed. We don't want huge backlogs. We want to prevent waiting. We want to be efficient in everything we do. There are a number of ways to look at this. Again, we often talk about flow of patients, clinicians, supplies, supplies being medications or equipment. We also talk about flow of information, which is another area that we have to look at, and also flow of process, the process that we continually use to analyze what we do. The term is everything flows continuously. It hasn't yet put me in this perfect state, actually not even close to that current state, and I don't own a red tie, but it's where we want to be, where things just flow continuously. As we look at flow, what do we do? I said to Lucy earlier, I said that I love talking on lean because you can use really messy slides and just say, well, this is the way it really looks, and this is the way it really looks. How do we map things? Here's a flow of caregivers, different kinds of caregivers in different colors with an overlay map trying to start to finish a process yet to be defined here. We want to know how many steps people are using, why they are stopping and starting in different areas. Is the equipment in the right place for us to use it? Are we sharing our tasks appropriately to minimize the number of steps? It's not just the time involved in steps. It's the fatigue involved in extra steps. It's the potential for error involved in extra steps and stops along the way. What we're trying to do is to map what we do, and one thing we do is we have people who are involved in the processes help us with that. This is an example of another example of a somewhat more efficient process, but the diagrams can look pretty messy. We look at flow of information, the way we integrate our risks, our PACs, our EMRs, etc. can be very complex. We often have extra steps that slow us down, so we have to not only look at our system integration but ask why we do things the way we do. If we schedule patients online, why do we make them stop at the registration desk and verify everything if they've already done it? Why do we scan documents if we have an EMR? How do we protocol? Do we do it in an efficient way up front so the patients don't have to wait? How do we do pre-certification? Does that hold us up? Is there a better way to do it? All these things, even things in PACs, how they're distributed, how we have hanging protocols, how information is sent, reports to the EMR, charges to billing, and how results get to patients. All part of this process involves technical staff, registration, scheduling, our ordering physicians, our billers and coders, etc. All those people have to be involved in this analysis of the process to understand. Patient flow, much like flow of personnel, we want to know what it takes to get somebody where they want to go, perform the tasks that need to be performed, and get them out in the most efficient manner, always focusing on their comfort and their safety. So the value stream is a set of all activities, and that would include the current state of waste, that we need to go through to provide a product or service to the customer. So we want to know who the customer is, and again, typically we're talking about a patient. We have to define the value, and value may be different to different people. Is value, again, the quality product that we're producing? Is value increasing our number of patients? Is value improving our payer mix? We have to make that definition, and it has to be agreed upon by the people involved in the process up front. We need to observe the work ourselves, and we'll see that involving all parties is important in a process like this. There are leaders, but there's no right and wrong. There's nobody that's more important than somebody else. Transport is just as likely to hold up how we do things and hold up our patients as we are. So we need to include people, observe the work, include all our partners. We can't let boundaries step in our way. Different departments, different health systems, different ways of doing things. The whole process requires some degree of buy-in among the participants to make sure that we don't let artificial boundaries prevent us from doing the best job we can in the most efficient way. When we map a value stream, we follow this service or product all the way through the process. We map it out. All participants are there. Again, it can be anybody from construction, engineering, maintenance, physicians, nursing, schedulers, technologists, the whole deal. They usually lock us in a room for a period of time, and we can't come out until we've come up with a process in place. We first map the present state or the current state. What do things look like now? We ask why we do things at every step of the way that way, and is there a better way to do it? We design a future state of how things would flow if we could do it that way, where we provide the best value for what we do. We decrease waste. We increase efficiency. We produce better quality and safety for our patients. The maps are not the focus. They are a tool, and you'll see that there are a lot of tools in Lean, a lot of odd diagrams, terminology and colors. They're all meant to provide a visual summary of what we're looking at and to allow us as participants to have a common language. Once you've been through it once, once you've gotten familiar with it, you know right away what they mean. You know what each kind of diagram represents. You know what each color represents. It's sort of a common language. Typically these things occur during a Kaizen, which is an employee-led process of continuous improvement. The mapping lets us look at multiple process levels at the same time. It allows us to link material flow, information flow, flow of people, flow of patients. It provides the basis of a blueprint to implement the value stream improvements. And together it produces the techniques we want to use, the concepts and things that we want to achieve into a more meaningful plan. So again, these colors are not by accident. They're again meant to show us what part of what cycle in a very quick visual way is involved. We want to go from the product or service, current state, future state, and planning and implementation, which is actually the goal of mapping this out. How are we going to get from here to here? How are we going to become more efficient? The colors are great, except I am colorblind and that's why I have a perpetually confused look on my face. The concepts that we do, we want to reorganize our own systems around the value streams, meaning that you don't want to keep trying to change the way we're looking at things and the value stream we want to achieve by the structure of our organization. And that's one of the problems we all face. We all have silos. We have departments. We have different administrative units. We have multiple components in our own institutions. And often they interfere with trying to provide the best service we can. So we want to try to structure the organization and therefore what I'm telling you is that the organization has to buy into the concept more than even a local area such as radiology. You have to understand and operate to your actual demand. You can't jump into it without understanding that current state and where it's going. You want to develop and plan for continuous flow, and again this term continuous or pulling, you don't want excess of anything in the system, nor do you want a lack of things that are going to hold up the system. Decreasing turnover, don't have too many stops in the system, don't have too many changes. You'd like to have the single piece flow, small batches that flow through the system as opposed to large herds that get stopped at a door, at a desk, at a room. When you can't do that, you sort of use these pull systems. We have these Kanban supply systems that visually tell us what's left and supply it according to demand on a constant basis or at least a daily basis because you don't want to waste your tools and you don't want to oversupply, you don't want to undersupply. We have to put in process measures and we have measures that are very similar to measures we use in other parts of quality, like PDSA and other basic techniques, and we need leadership. We're saying that all of the participants are valuable, but somebody has to help oversee the process and take ownership. When we look at our mappings, usually we have spent a full day on the current state mapping with these large cross-sectional teams, and I know it seems ridiculous, you're really going to get 30 people in a room, and the answer is, yeah, you do, and it actually surprisingly works pretty well. There's a leader, somebody who's familiar with these techniques and walks people through it. This team is responsible for implementing new ideas. You really typically would go walk the floor, or called gimba, to be able to understand the processes and actually map them out physically on a map, and it gives you a picture. You know where you are. You want to, when you're walking, ask the right questions. How long do things work? What's your cycle of start to finish? How often are there errors, defects in what you do? What's your batch like? Again, do you have 100 patients coming in at the same time, or are you trying to smooth that out? Being a radiologist and having orthopedists complain that we can't get their patients through fast enough because they send 50 at a time and won't pre-schedule is a very typical problem we see. Inventory, is there too much there? But are they also there when you're ready to use them? Is it tool at your fingertip? And then other questions. How do you know what your goals are? How do you know what your timing is supposed to be? Looking for other problems and issues to add to the mix. This is sort of an overlay of a value stream map, so this is multiple pieces of it. We have the customer demand here. We have roadblocks, like I can't get a bed, or I can't get home, so I can't be discharged. We have supplies and patients flowing through. We have data points that have to occur all the way from admission or outpatient visit to discharge. We have multiple steps in between here, and what do we end up with? Here's our cycle time. We have, obviously, our wasted time, and we have our value time. And you can see that this red versus green is pretty common, and this one isn't actually so bad that two-thirds of the time may be non-value-added activities. So this is kind of what these things look like. You'll see as I show these things that you can't read them, because that really isn't the point. The point is, again, that they are up on a board. They're visible to everybody. There is some color coding that helps us innately understand what piece of the puzzle we're talking about. If it's an inventory or patients, where do we have problems show up? Problems look a little bit like an amoeba here. And this is, again, the concept is not the terminology, the color, the diagrams. It's a common language, that's all. Future state, the same idea. Same team comes back in, takes the current state, talks about where they want to be and how they can improve the process. What steps can we eliminate waste? How can we cut down physician steps? How can we decrease nursing tasks? How can we not have equipment laying around inventory that's going to expire? And look from the patient's point of view, how can things flow more smoothly? How can we get rid of those red areas and make them green? And how can we produce on demand, as opposed to pushing materials and people and products? How can we know exactly what we need at the time that it's needed? So the plan, you have to have business objectives that match your plan. You have a value stream plan with time charts. What needs to be done by when? In between, when you have roadblocks, when you need to improve a process, we would employ our normal quality techniques, like the Plan, Do, Study, Act, or any of those basic techniques to attack a problem, figure out how to solve it, and then put that as part of our value stream planning. This has to be reviewed frequently. What we don't want is a solution that's time limited. It has to change with changes in how we provide care in our environment, our personnel, our objectives. So it really is a live process. A lot of the groups meet in these daily huddles just briefly in the morning to review how things are and what needs to change. And part of the value stream review should be part of that. People need to walk the flow intermittently to make sure it's functioning well. We have to look at that future state that we talked about, even the one we can't achieve, and how far are we from there? Are we moving farther away? Are we getting closer? So how do we become successful? Management is critical. They have to be leaders in this organization of lean. They have to move forward and sort of dedicate this and actually give up some degree of responsibility to the people who work with and for them. And not all people can do that. It has to fit in the organization's strategic plan. The managers involved in the value stream process have to have power. They have to be able to implement and manage things. They should not be said no to for things that the group has agreed upon unless they're outrageous, like my jacuzzi, which was denied. They have to be able to share information. They have to know that there's risk involved in change, and that's okay, because most of us have been taught not to accept risk, and yet it is okay. We have to plan our improvements. We cannot blame anybody if it goes wrong. People have to be able to speak out and tell what they see and have that taken at face value. What you want eventually is to have all your success transferred to either a business bottom line, market share, improve patient satisfaction, decrease patient falls, all the goals you might have. Just as a brief example, we used this in trying to plan IR services in a new hospital. The issue really was that we've had three services providing interventional of different types. They haven't shared much. They're not at war, but they have different resources, different personnel, different locations, different rooms, different purchasing, and that is a problem for a lean system. It can't be efficient. It can't lead to pulling for supplies. What did the administration want? They wanted a new hospital facility with a full procedure floor that became efficient where as much as possible we would integrate equipment space and personnel. What we had to do is get all these teams together to work on the design of the facility, the patient flow, the resources we need, and the information that we required to share to get this done. We held this Kaizen. There are several pieces to it. One is this production preparation process 3P where we develop the product with the operation, have all the people there, collaborative structure where we're looking at the process in the development of the product at the same time. People get to learn together and make rapid changes at the same time. Obviously, the goal is we want the right product at the right price point with a satisfied customer. These things are very consistent, these kinds of roles. What are we doing? Why are we doing it? Who's involved? Who's in charge? Road map for our interventional included as a value stream map as a first part of this several years ago. Who is in charge? I wanted to show this just because I was there. We look at the current state, how things are done. We look at inpatient flow, what are things that would be important that are missing from the equation. Included things like transportation, communication boards, environmental services, how they interacted, how that held up our flow, how we held up their flow. Outpatient flows, similar problems, but we add in there the communicating with the patients, signaling to the patients, how we receive the patients, how we get them to where they want to be in a different manner than transport involving greeters and hosts. Family flows, again, communication is the key. Status boards, pagers for the family, decisions on where the family goes, how they get there, how many can be there, again, involving a human touch somewhere along the line. Materials flow, don't want them coming in during the day. We don't want these big skids coming up on the floor. We want a Kanban type pull system with standardized sourcing. We want to know where our materials are all the time and that we don't run out and we don't have access. There are a whole bunch of improvements that I'm not going to dwell on in terms of staff flow, patient flow, experience communications, information flow that came out of this week long process. We actually were able to implement these improvements and it has worked pretty well. We did things like safety mirrors, supply carts in all PrEP recovery rooms, putting the house phones in the right place, taking the TVs from PrEP recovery, et cetera. The issue is that this forced marriage worked. There was a common good that went pretty well. It's been successful. It's still fluid, so we do change as we need to change. Compromises were made from our point of view, there was sharing of PrEP recovery, cross-training of nurses in that realm. We had to actually coalesce our status boards, things like that. We lost office space, which remains an issue, but administration compromised. All three groups remained their own nursing personnel in the rooms. They were one originally fully shared space, and it really isn't what it is, IR space, cardiology space, and swing rooms, so we all did that. Value stream mapping, process improvement, common language that helps us all visualize where we're going, linking material patients, information flow, it's a blueprint for future work. It is not static, it's active, it changes, it's fluid. We have to manage our change effectively in order to foster a healthy work environment. In this segment, we're going to talk about mistake-proofing imaging processes. We've been doing LEAN at Virginia Mason probably for about 12 years now, and we've learned a thing or two about it, although I'd have to say in our journey, we'd probably say we're probably in our childhood, maybe early adolescence of our journey with LEAN. I want to talk a little bit about the culture of safety, I want to talk about the components of mistake-proofing, including inspection, standard work, visual controls, and devices. I think we as healthcare workers really have to change our way of thinking about things. What the patient really wants is zero defects. They do not want any errors made, but really what they're asking for is for no harm to come to them. What typical organizations want are really very few defects. Can we live with 99% reliability? Do we have to be 100% reliable? Well, LEAN philosophy would say yes, absolutely. You have to be 100% reliable, and you have to strive for that. You have to want what the customer or the patient wants. You have to want there to be no defects or zero defects. We have to change our expectations. We always feel like perfection is just impossible, and we have to feel like, okay, perfection can be possible, and we have to think that injuries are not inevitable anymore. We have to feel like injuries can be avoidable. Zero defects is the goal, but how do we get there? I think this is where it helps to define terms a little bit. Mistakes or errors are inevitable, right? Any time you ask a human being to repeat a process, you have about a 3% error rate. Human factors engineering tells you that. There's no way around that, but what we're saying is that defects are mistakes that were not fixed soon enough, so a defect is something that makes it all the way to the customer without being fixed or an error that made it all the way without being fixed. How do you put processes in place that catch those mistakes or errors before they do harm? If you can fix your mistakes soon enough, then your work product can have zero defects, right? The mistakes are least harmful and easiest to fix the closer you get to the time and place they arise, right? If you have a mistake that's upstream and lots of different steps have occurred before you fix that mistake, there's a lot of waste and rework that goes on. The basic elements of mistake proofing are inspection, standard work, visual controls, and devices, and we'll go through these. This is level one inspection. If you have a process that starts here with your supplier, these are the various steps in the process, and then here's your customer or patient. If a mistake occurs very early on in the process, doesn't get picked up all the way until the patient, well, that's the worst outcome, right? That's really what you don't want. You get unhappy patients and you get lawsuits. One bear says to the other bear, hey, well, these things just snap off, right? Exactly what you don't want. You don't want this customer finding out that the defect made it all the way down the road. So what can you do? Well, level two inspection is the next level you can go to. You can put in a audit step at the end of your process, right? So you have an inspection step just before you make it to the customer. This is good. There's no harm to the patient, but what happens is that a lot of times this feedback loop to the person who made the error is pretty tenuous. A lot of times that feedback never gets to that person. The error recurs, right? So the possibility that this is a mistake-proof process is pretty low. So this is good, but not great. There's still a lot of waste in this process. So this is the next level of inspection. This is where you actually keep it within your department. So an example of this would be, and this happens all the time, you're reading a chest x-ray, you're looking back at a chest x-ray, and you realize it's not the same patient. It's different morphology. It can't possibly be the right patient on that image. So then you go back to your technologist and say, who is this patient? Then you identify it. So the error doesn't get propagated beyond your department. It doesn't go on to your provider. It doesn't go on to the customer or patient. At the same time, it's still wasteful. It takes your time to fix the error, right? So this is certainly better than having an end-of-line inspection, but it's still not the best. This is where we get to probably what we would call mistake-proofing, or the very earliest stage of mistake-proofing, is where you actually put in place self-inspection or steps to try and prevent the error from occurring. So things like a checklist, a checklist to do your procedural pause so you go through all the steps correctly, a template for your report so you remember to look at all the different anatomy, things that make it difficult for you as the operator to make the mistake to begin with. So when you look at this, you start here with the lowest levels, level one, two, and three of inspection, and really these are just checking for defects, checking for defects before they get to your patient or to your customer. The next level is self-inspection, and this is really where you're trying to detect errors. You're trying to detect the mistakes before they become defects. And the last one really is to prevent the error from occurring in the first place. This is really the ultimate in mistake-proofing, or what we call pokeyoke is a Japanese term in lean terminology. And we'll talk a little bit about this when we come to the devices. So we've talked about inspection. The next piece of mistake-proofing is standard work. And this is the lean definition of standard work. Standard work is an agreed-upon, repeatable sequence of work assigned to a single operator at a pace that meets customer demand. Taiichi Ono was the founder of the Toyota production system, and he said, without standards, there can be no improvement. And what this means really is, if you have a process that has an incredible amount of variation, every single time you try and measure it, it's different. How will you ever know whether you make a change if it's improved or not, right? There's just really no way. Variation leads to defects. Variation really leads to unreliability. So what you wanna get to is standardization. You have to get to a standard process. You wanna take your best practice and try and get everyone to do the same thing, right? Once you have a standard process that's reliable, then you can measure it. Then you have a baseline to work from. Then you know, if you make changes, whether those changes have helped and whether you've made that improvement or not. So you can't get anywhere without having standardization first. And as physicians, I think we rail against the idea that we should be standardized or that we should do our work not in any way, that shape or form, that everyone else should do it, that we should have our individual way of doing things. And in fact, when you look at most people and most groups of radiologists or physicians, I think they all agree that the basics are pretty standard among a lot of the various individuals in a group. And you could probably come to best practice, which is why that we've driven so far with our standardization in terms of protocols, agreeing that everyone will, if you're going to get a CT of the abdomen and pelvis, the protocol is the same. It's not going to be different because I'm the radiologist for the day or someone else is the radiologist for the day. That's really what you have to do in order to get to higher reliability is you really do have to drive towards standardization. Okay, so the benefits of standard work include that you're trying to get to your best practice and have it disseminated through everyone, every operator who does it. You have to assure highest quality output. It allows us to see where the waste is. When something is standardized, you can then figure out, okay, something is off, right, in a process because it's not following the standard. It's the foundation for improvements. You cannot get to improvements. Once we, you know, when we go in and do the baseline work to do an improvement project and we go and do the observations, the first clue that you have absolutely no standardization is that every time you try and map the process like Dave talked about, you're trying to map the steps and time the steps. It doesn't happen because every single time it's different. Then you know that you really have to stop and say, look, we can't even go on to do an improvement project on this area. We have to first go back to the basics and say, okay, what is the standard work? What is the standard process for this before we'll go on and try and make improvements? And the standard work also helps with training. This is just an example of what we use for our central line insertions. We have, this is just a pictorial map of all of the different steps. There's a Word document that accompanies this, but this is a quick visual to make sure that everyone's following that. So whether you are a intensivist putting in a central line or you're an interventional radiologist or you're a general surgery resident, everyone follows this same standard work throughout the organization. And it's led to huge decreases in our central line infection rates. That's what standardization allows you. So when you want to document standard work, these are the tools that we use. Dave showed you the spaghetti chart or what we call our standard worksheet. It basically maps out your flows and you can do it for any individual operator or you could do it for equipment or you can do it for information flow. So that's the first thing you do is you go and you observe the process and you try and understand what the flow is. Then you try and get down what the different steps in the process are. And then once you have a standard sequence of steps, then you can time the process. And that's what we use our time observation form. And then we'll use that data on this standard work combination sheet. What the standard work combination sheet allows you to do is to graphically see how long steps take and whether there are long wait states in between. This little red line is what we call tack time. And tack time is really a measure of your demand. So it's the time that is allowed for a particular process based on what your demand is for that day. So if your whole process is way beyond tack time, then you know you either have to eliminate a lot of the waits and try and improve on that or that you may need a couple of different operators working at the same time in order to meet tack time. That's another way to do it. This last percent load chart is also helpful in looking at a whole team and looking at each individual cycle time and understanding whether there's an imbalance. If there's one person who has way too much to do and that really throws off the lead time for the entire process and makes you go above tack time. So here's your tack time line here. Or you can try and figure out, well, do we have too many operators here and can we decrease an operator? Can we take an operator away, redistribute work and still be below tack time? So it's a very, very useful tool. So once we have all of this documented, then we can start to use our PDSA cycle, right? So we plan an intervention, we do it, we study what the effects are again, retime, and then see if it's improved or not, right? So that's how we use our PDSA cycle. So that's standard work. The next component are visual controls. And visual controls are methods, devices, or mechanisms to visually manage operations. So this is an example of an anesthesia cart before we did some Kaizen work. Each anesthesiologist had their own particular way of setting up their cart. They had their things particularly laid out and some people were very messy, some people were fairly clean, but this is fine if you're the only person using this cart. But what happened was when the anesthesiologist got relieved for lunch or a break, trying to go through the entire cart and where everything was took a long time. It was pretty wasteful. So the anesthesiologist got together and they standardized and they created this shadow board for the top of the cart and they decided exactly what pieces of equipment should be on top of the cart, where each piece of equipment should be and there's a shadow mark underneath where the equipment sits and a little label of where it should be and where each drug was. So very easy then to take over someone else's cart and find what you need in an emergency very quickly. Visual controls are only as good as your agreements about behavior with the visual control and accountability to using those visual controls and those behaviors. So this is an example of visual controls in driving. There are a lot of visual controls. There are lines that tell you that you should stay on one side of the line or the other. There are speed signs that tell you what speed you should stay at. For those of us who've gotten several speeding tickets in our lives, it doesn't mean that there is a behavioral drift that occurs with this, but at least everyone understands what the rules are and there is accountability, right? Because there are usually police, there are usually highway patrol that keep you accountable to the rules and same thing for other visual controls. If there isn't someone keeping you accountable to staying with those visual control agreements, then the visual control is really not very helpful. This is just a few more examples of visual controls here. This is just a communication in our clinic of when the doctor is needed, when the MA is done with their work, they flip these signs so they know where in the flow that people are and what's needed next or where the doctor needs to go next and which order of exam rooms. Okay, so the last piece of mistake-proofing are devices, mistake-proofing devices and these actually prevent mistakes from occurring in the first place and this is really where you want to get to. It's the ultimate in mistake-proofing and in Japanese, it's called pokeyoke. It is the lean terminology for this. And so this is an example of a mistake-proof device. There was a horrible incident where there was a very young woman who basically got hooked up. They thought they had hooked her up to oxygen by the end of the case. They realized they had hooked her up to nitrous and it was basically she was brain dead by the end of the case. So from that, I think anesthesiology really took it to heart and became a very, very prominent leader in the safety movement. They created these OR hookups. Every single gas is a different color cable and each connection is a different connection so there is absolutely no way that you can connect the wrong gas up. So this is the last level of inspection, right? This is the last level of mistake-proofing. It's a process redesigned to preclude mistakes. Another good example of this is the PACS dictation marriage where if you have a voice recognition system that's integrated with your PACS system, when you pull up the images of an exam, then the report automatically launches on your voice recognition system. So it's impossible for you to be reporting on the wrong patient. In the past, when you had to actually put in your session number, you could have put in a wrong digit, you didn't realize, you didn't look at the name and you could be reporting on the wrong patient, right? So that really prevents that from occurring. And that's really where we want to get to is trying to figure out what are the mistake-proof steps. If you can't get to here, to this pokey-okey level, then at least get to level four. This is just another example in instructions for safe treadmill use. It's good to have policies and guidelines about how to use the treadmill safely with patients so that they don't fall off. Better still would be to have inspection at the point of care, so you have an attendant ready to steady the patient on the treadmill before they fall. The best, though, would be a pokey-okey, which would be like a safety harness that keeps the patient in place, makes it absolutely impossible for that patient to fall off the treadmill. So we want to go from here, where the customer or patient inspects, to here, where we've eliminated opportunities for errors to occur in the first place. And zero defects is the goal, and I hope I've given you a few ideas of how to get there. And I'm going to leave you with my favorite quote from Gandhi, which is to be the change that you would like to see in the world. The goal of my talk is just trying to give you some advice to help you find the right project for you, to try to help you get some ideas about where to get started in this process of doing QI, and give you some tips. I've been very fortunate. I actually started doing Six Sigma back in the mid-90s, and I've done over 100 different quality projects in radiology, trying to improve different systems-based care and I can tell you, the hardest part of the project, without any doubt, is choosing your project. It's very, very difficult because, at the very simplest point, if it was an easy problem, it would have been solved already. And so you're going into something where you don't know if you can solve this issue. So I find that when I'm helping counsel people about choosing a quality project, they're filled with doubt. And I want you to know that's actually very natural, and that's actually part of this process that I want you to understand. And so when you're coming into trying to choose the right quality project to work on, you might be concerned. You say, well, I want to make sure this has an impact on the patient, and I want to be able to try to make a big value, but I don't know necessarily where to start. I'm concerned because I might not have all the data that I need, so I'm not 100% I'll be able to move forward with the project. I'm not sure, and I know it involves a team, it involves technologists and nurses and referring physicians, and I'm not sure everyone is bought into this process. And so I find a lot of people that are kind of filled with doubt moving into the project. And you're concerned you might be biting off more than you can handle. It might look like a little thread, or small little problem, but then you start uncovering an iceberg in the process, and so biting, becoming a world hunger project. So you have all these, I find people with all these doubts coming in to doing a QI project, and I find in some ways it can create a little bit of a paralysis and help them, and they say, well, there's too many unknowns for me to know where to get started on this QI project. And it kind of feels like you're stepping off a cliff. And I'm here to tell you, I think that it's supposed to, because you are doing something that has not been done. If it was an easy problem, it would have been solved. And you're not 100% guaranteed of succeeding. This is an act of leadership doing a QI project. So my advice to you is keep calm and trust the process. Lean and Six Sigma and quality are actually a recipe for a process that includes project management to get people vested, become data driven, remove their pet theories and their emotions as part of this goal. And so I find that this is really how it helps me is getting people to, you have to learn to trust the process, because a lot of, I've found a lot of physicians have come to me with this great quality project in mind, and they think it's great because they already know the answer to it. And so it's an analytical problem. It doesn't involve anybody else to do. They bring a team together on the first day, and they say, great news, here's a problem, and here's a solution, boom. All we need to do now is implement it. And what happens is the next week, no one really complies with what that person suggested to do, and the week after that, that PI says, well, those people, I blame them because they didn't comply with what I recommended them to do, and so therefore, it's their fault. And really, it's about the process. The process includes vested interest, includes getting people together, and so don't worry. Trust the process, and actually, you're going to learn. You actually come into a project with not a problem, but with a perception of a problem. You have to follow the data and find out where it leads, and to help remove some of those blinders, and to be able to understand the underlying quality issues around it. So don't worry. And I find that what helped me the most is, I find that quality in doing Lean Six Sigma, it really gives me a new lens on the world, and it helps you look at it from a systems perspective. And so it gives you a new pair of goggles, and it really is like a sixth sense. And what I mean is, how much time do you actually, have you spent just observing the waiting room? You know, just trying to be able to observe process, watching technologists, or watching procedures, without being an active participant. It's really hard, because you're in your zone. You're busy, you're reading cases, so it's hard to stand back and see what's going on around this, to look at it like a system. And so it's helpful to do a little bit of this, to understand all the different dynamics. How many different black boxes we have, where it's going from one person to the next, from scheduling, to registration, to the technologists, the radiologists, to making sure that everyone's got, is kind of going down the step, and looking at it like a system. And this was a big, this was a kind of an epiphany for me, because like I said, I'm a little bit old school, and I was trained in Six Sigma. And if anyone, there's a lot of positive things about Six Sigma, it's really the classic American management, scientific management style, where our job is to detect defects, and eliminate them, or reduce variability, using F-tests, and T-tests, and statistical analysis. So it's really about focusing on defects. And for learning about the Toyota production system, and Muda, it's actually much more than that. It's actually about kind of this, for me, it's like a feng shui. It's trying to understand, looking at it from a bigger perspective, looking at it like a, looking at it from a perspective of understanding the bigger dynamics around it. And so, the best way for me to think about it, is by looking at the eight egregious forms of waste. And it really shows you some of my suggestions around what type of quality projects you can do. And so, what does waste look like in radiology? And the first one, it was easy for me, it's actually defects. So this is the one area that I was familiar with. Yes, when things break, when things are wrong, when the images are non-diagnostic, when the order is incorrect. Those are clear defects, and those can be defined, wrong procedures, non-diagnostic studies, misinterpretations, discrepancy reporting, recall from incomplete exams. Those are all very classic defects, and those are great places to do quality projects, because you really have a clear focus and goal. But that's not the only area you should be thinking about when doing a quality improvement project. There's actually other, there's now seven other areas to think about that are actually very legitimate areas to do QI projects in. The second one is actually non-value added. This was a new lesson for me. So if it doesn't add value, it's a form of waste. Nothing went wrong, there's no crisis, there's no sentinel event happening, but this step added no value to the patient. It was a waste of your time, it's a waste of our resources, it's a waste of the patient's time. There's nothing, this is actually a very legitimate area to focus on as a quality improvement project. Non-value added steps, out-of-date protocols that are taking too long, that are not as efficient as they can be, inappropriate orders. Those are very, very legitimate projects to be working on for QI. So this would kind of open my eyes a little bit to different types of projects. The third area is waiting, is this idea of it adds no value and delays the care process. And so if you're a patient and you get an exam and they really recommend a CT scan or an MR scan and you have to wait three weeks to get an MR scan, there's a lot of concern. And there really is time dilation. That might seem it's three weeks based on our Georgian calendar, but really for the patient, it feels like three months. And when they're waiting for their exam to be performed or waiting for the results, there's a lot of stress involved with that that can really affect them. And so understanding patient waiting and access to imaging, but also the effect on the radiologist as well, waiting for image retrieval, waiting for priors, the performance of the PAC system, being able to help you do your job and waiting for reports are completely legitimate areas to do QI projects on because they impact your ability to, they add no value and they can potentially delay care processes. Underutilization, this is a really fascinating, there's an idea of called flow within Lean and a laminar flow where everyone's doing nice consistent work, where they have time to do their job, they've got time to prepare for their work, they have time to do it. If there's not consistent flow, if there's a lot of underutilization, the work that they do even when they have it is actually less quality because they don't have consistent flow environments. And so the idea of underutilization of our equipment, our resources, our MR scanners is also a very legitimate quality improvement project to make sure that, because it improves quality when there's nice consistent flow. And on the flip side of underutilization is also overproduction is also a great form of waste. And one of the egregious say in terms of it producing more than is needed. If you're doing more than you need, if you've got more technologists than are needed, if you're creating more radiation than's needed without comprising image quality, those are areas that also are very legitimate quality improvement projects. Overproduction, underutilization, those things get to a sense of things that are not necessarily adding value to the patient that can be trimmed back. We get into things like transportation. So this is a spaghetti diagram on the bottom of how you move where a nurse or a physician might be moving around to get the parts and supplies they need to be able to perform a certain task. And on the top is before where they had to walk all over the place and the bottom, they reduce this. And this might seem like a simple project to you, but I cannot understate the importance of something as important as this. And so a good example is the work that Peter Pronovost has done. Peter Pronovost won the MacArthur Award in 2006. He's credited with saving the lives of 100,000 patients from bloodstream infections. And at the core of what he did, his work has been published by Atul Gawande in the Checklist Manifesto. And he did this by actually observing what happens when people put together central lines in. And he noticed that people have to get the drapes over here, the gowns over there, the gauze over here, the chlorhexidine is in the next room. And he finds that 99% of the time they do that, but once in a while they can't get all the pieces together. And so the big intervention that actually reduced bloodstream infections from seven days every 1,000 catheter days down to one was actually just putting together a bundled kit. He just had one little kit that people would have and it'd have all those parts for him in one place. And they'd grab the kit and they'd know what to use. And that in itself was just, it had a massive impact on patient care. So just this idea of all these different random tasks you have to do to perform one procedure, being able to help that you reduce that standardization can have a big improvement. We think of this in forms of excess motion on the workstation. Dr. Glenn mentioned manually synchronizing multiple applications is prone for errors. Trying to keep them synced to the same patient is a very risky adventure. But also just the poor ergonomics. If you're having to go from all the way to the left on a four monitor system on the left-hand side of one monitor to the right-hand side of the fourth monitor, you're covering some serious territory. They actually have odometers now you can put on your mouses to see how much distance you're traveling. And it certainly is tied to all the repetitive stress injuries that we're seeing in terms of... So this is actually a legitimate project. If you want to help reduce the mouse odometer movements on your PAX workstation, you will improve radiologists productivity by a considerable amount. And you actually will enable new functions that they'll be willing to do because they can get some better efficiency. So excess motion is another nice way to start thinking about a form of waste. And one of the most interesting forms of waste that I learned with Lean, and I never thought of before as a form of waste, was this concept of inventory. Is that storing inventory does not add value. But not only that, it's a risk for obsolescence, spoilage, and quality issues. And the goal is to try to build these just-in-time systems. And this is really a core concept for Lean. And so when you think of inventory, you think of all the PAR levels and parts you need to have, and interventional, the catheters and supplies. But also think about anytime you see chairs, anytime you see a waiting room where you have to have a buffered system. And so the idea of Lean is that inventory is basically a buffered system that's trying... Is because you can't understand the flow of the environment and you've got no control over what's going on, and then you have to build these buffers. And the example they have is that your inventory level is like the C level. And you've got all these potential problems that you're masking because you have all this inventory as a buffer. Now when you reduce your inventory, say you get rid of all the chairs in your waiting room. It's going to be chaos. And so how would you be able to... But you start exposing some of these processes and helps you understand what are some of the things that are preventing you from delivering better service and better patient care. And so looking at inventory as a form of waste, and looking at ways of trying to reduce that inventory is a great idea for a QI project. And so I think there's also going to be... A lot of people talk about a ninth form as well, and that is wasted talent. What about all the creativity of all the people in your practice, the radiologists, the technologists, the nurses? Do they come to work every day with their imagination? Are they... That's a resource. That's an amazing resource. Are they being used to be able to help you re-engineer your processes? There's a great book on understanding the creative confidence. Most people don't have confidence to be creative. They never have exercised it, and they don't feel that they can do it. That's only for artists. That's only for people who are designers. And the truth is, it's actually for everybody. It's about being able to exercise your imagination and being able to be able to build this trust to think outside the box. And this is an enormous resource we have in radiology that we should be able to think of. And so the types of projects you would want to work on for this are all the ones that previously mentioned. You'd want to bring in those people into all the other projects you want to think about and have them be able to think about different solutions they can have to be able to create different new solutions and new interventions for this. So think about talent as an enormous resource that you can tap into. And right now, you're leaving on the table. You're wasting that. If you just have a typical top-down management structure where you're not asking for their input, you're not encouraging them for their engagement, you're not giving them the tools and resources to become involved in re-engineering your workflow processes and fixing broken healthcare systems. So my advice to you is, the most important advice to you is you should find a problem that interests you or more, even better than interests you, something that bothers you, something that annoys you, something that annoys the dickens out of you is the best project to start with because nothing beats vested interest. Anything that you feel, this is too hard to do the right thing. It's so easy to do the wrong thing here. Any environment where you feel that there's just a reliance on vigilance to ensure safety and the right thing from happening is a great gut. You need to listen to your inner sense of what resonates with you. This is actually something that you should try to hone into because that is actually a fantastic area to do quality project because as we all know, the chicken is involved, but the pig is committed and you want to be vested into your quality improvement project and in having something that really is something that you want to solve fixed because this has a direct impact upon you is the best way to get started this quality project. And one of the rules we like to think of is you know that your job is to deliver great interpretations on your patients, but 95% of the time you should be doing that. But you should have some time, maybe 15 minutes a day, maybe 5% of your time thinking about ways that you can do a better job of that, ways that you can be thinking about how to make the next day more efficient in this process. Even just having that discipline of 15 minutes a day can really help you start tackling these types of systemic things that bother you and actually you'll find it bothers a lot of other people as well. And it can really be tied to improving patient care. So in summary, I'll give you this quote that I believe in from Peter Pronovost in that there's not going to be a new massive imaging modality like we had with CT and MR. That's going to give us amazing new interpretation capabilities in the next 25 years. The next new, we already had these amazing miracles of science that we're using to improve patient care. I think what we need to do is we need to be able to take those miracles and provide them consistently and for all of our patients in a 24-7 role with all this knowledge and subspecialization. So learning how to deliver existing therapies consistently and effectively for all of our patients is going to be the greatest opportunity that we have in the next 25 years to radically improve the outcomes for our patients.

Lean Healthcare System

patient care

operational efficiency

value stream mapping

waste reduction

stakeholder involvement

mistake-proofing

standard work

visual controls

quality improvement