Lorraine Trilling INSA Lyon, LIESP Bertrand Pellet CERCLH

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1 Retour d'expérience sur la mise en place du Lean dans un centre de Radiothérapie
Lorraine Trilling INSA Lyon, LIESP Bertrand Pellet CERCLH Sabine Delacroix, Hélène Colella-Fleury Centre de Prothonthérapie d’Orsay (CPO) Institut Curie Eric Marcon Université de Saint Etienne, LASPI In this presentation I would like to give feedbacks of a project carried out in a French radiotherapy center for cancer treatment . The objective was to improve care efficiency thanks to Lean philosophy. This work has been performed in the Centre de Protontherapy d’Orsay which is part of the Institut Curie, within the scope of a collaboratio with physicist, supervisor of the center, but also with Lean Six sigma Healthcare expert of the University of Saint Etienne. Lean, first created as a part of the Toyota Production System, is an operational approach and methodology embraced by world-class companies around the globe. Lean are tailor-made for the healthcare industry GISEH 2010 – Clermont-Ferrand 3 septembre 2010

2 Plan de l’exposé 1. Radiothérapie et CPO 2. Objectif du projet Lean
3. Méthodologie et process 4. Choix des chantiers 5. Conclusion et perspectives Plan de l’exposé I will first explain what is the current context for radiotherapy and what are the challenges faced by the CPO. This will explain why the whole team got involved in a lean journey almost two years ago and give the objectives After the description of the methodology followed during the project, I will briefly describe the treatment process. One specific improvement kaizen workshop will be described. GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

3 Le contexte de la radiothérapie et du CPO
Modalité thérapeutique majeure de traitement des cancers Traitement par irradiation par faisceau de photons, répétition de séances de traitement Haute technologie, nouveaux protocoles, nouvelles tolérances  Discipline en constante évolution Forte de demande comparée à la capacité de traitement actuelle Centre de proton thérapie d’Orsay (CPO): Faisceau de protons  nécessité de précision accrue Besoin de rationaliser l’utilisation des ressources, réduire le délai avant le traitement, afin de faire face à la demande et traiter plus de patients Exigences en termes de qualité, sécurité, réactivité Préparation pour la création d’une nouvelle salle de traitement et l’installation d’un nouvel accélérateur. a radiothérapie est une méthode de traitement locorégional des cancers, utilisant des radiations pour détruire les cellules cancéreuses en bloquant leur capacité à se multiplier. L'irradiation a pour but de détruire toutes les cellules tumorales tout en épargnant les tissus sains périphériques. La radiothérapie est utilisée chez plus de la moitié des patients ayant un cancer. Elle est, avec la chirurgie, le traitement le plus fréquent des cancers et peut entraîner une guérison à elle seule. Radiotherapy is one of the major method used for cancer treatment. Traditional radiation treatments use beams of photon to destroy malignant cells and preserve healthy tissues surrounding the tumor site. Several treatment sessions are required to cure a patient. High technological facilities and equipments, new protocols and new tolerances implies that this field is in constant evolution and requires a continuous adaptation. Another strong characteristic of this sector is the high demand compared to the capacity of the current centers. Proton therapy is a high-precision radiation treatment that is recommended to treat tumors located in critical areas of the body, or for sensitive patients such as children. Therefore an increased precision is required. Even if the center was able to provide 4000 treatment sessions in 2007 thanks to two rooms available, the capacity of treatment was far below the increasing demand for such treatments. As said yesterday by Yoan Jacquemin during his presentation, the faster a patient can be treated the higher are the chances for him to recover. A good reactivity is also necessary and complete the performance requirements in quality, safety, and risk control. Currently CPO prepares the extension of the facilities by the creation of a new treatment room and the installation of a new accelerator that will supply 3 rooms. Since CPO is a small structure including 35 collaborators, and it is able to act quickly if required. GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

4 Pourquoi une démarche Lean au CPO
Parce que la discipline s’y prêtait naturellement : Nécessité d’optimiser les processus (répondre à la demande) Exigence de qualité Évolution continue de la discipline => nécessité d’amélioration continue des processus Parce que la structure s’y prêtait Petite structure très réactive Capacité d’action Maîtrise des processus (hardware et organisation) Bon potentiel « culturel » Accompagnement par le CERCLH – Université de Saint-Etienne GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

5 Le Lean Qualité, coûts, délais Amélioration continue Juste à temps
en améliorant les flux et éliminant les gaspillages Amélioration continue Juste à temps Jidoka « Le bon produit, au bon moment et en quantité désirée » « Rendre les problèmes visibles » Kaizen Arrêt automatiques Autonomation (système homme-machines) Poka yoké (dispositif anti-erreur) Andon (signal visuel) Flux continus Flux tirés Takt time Nivellement SMED Respect des personnes Ressources humaines performantes, polyvalentes et motivées For thoses who are not familiar with lean, I would like to recall te main principles of lean management, inspired from the way toyota plants are managed. Lean is an approach that seeks to improve efficiency of an organisation by eliminating the wastes, reducing the non value adding work and improving the flow. The Toyota production is often represented as a house with strong foundations and solid pillars containing highly motivated people working to continuously improve. The roof of the TPS house represents the expected benefits of the complete system. Transposed to health care, JIT pilar creates a flow of the right care, to the right patient, at the right time in the right place tending towards zero wait, while the Jidoka pilar prevents problems from occuring and malke problem visible. In the following, we will see how, to some extend, lean principles and tools can help improving heathcare services in the particular case of CPO. Comment le lean peut aider à l’amélioration des services de santé? Quels sont les outils que l’on peut appliquer, quelles sont les adaptations nécessaire Stabilité et standardisation des opérations 5S Travail standard Fiabilité des produits et des procédés Intégration des fournisseurs Résolution de problèmes Management visuel GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al. Source: Jeffrey Liker, The Toyota Way

6 Les objectifs du projet
Capacité de traitement Délai Culture Augmenter le nombre de possibilités offertes aux patients Réduire le délai entre la décision de traitement et la première session Déployer une culture de l’amélioration continue à l’ensemble du personnel So the main objectives of the CPO While maintaining a very high level of quality and safety in the treatment delivery. In order to achieve this goals CPO started a lean journey since january 2008. We do not talk about LoS but about time before the patient can be provided with a treatment. Qualité et sécurité du traitement Début d’un « Lean Journey » en 2008 GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

7 Méthodologie Formation aux principes et outils de l’amélioration continue (modélisation de processus, PDCA, résolution de problèmes, 5S …) 1 Value Stream Mapping (VSM) du processus existant Identification des activités créatices de valeur et des gaspillages 2 3 Création de groupes de travail pluri-disciplinaires sur des chantiers Kaizen 3 From beginning of 2008, a lean project has been conducted in CPO. The methodology was the following: Fist the whole staff has been trained to lean tools such as process mapping, 5-S which is a method de make and keep the workplace clean and efficient, PDCA, defect analysis, problem solving tool box. Then, mapped the processes thanks to vsm. This led to the identiffy what were the value added activities, and where were the wastes. I’ll show a simplified VSM in the next slide. 1 training to the tools: mapping the process, 5S, plan do check act improvement cycle, defect analysis, problem solving tool box 2 then we mapped the processes thanks to vsm. This led to the identiffy what were the value added activities, and where where the wastes. I’ll show a simplified VSM in the next slide. 3 4 The identification of wastes led to create working groups I will take advantage of the presentation of the VSM to give more informations about the process which is very interesting Optimization of treatment room utilization time Manufacturing workshop redesign Simulation phase reduction Scheduling of patient route GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

8 Réalisation des accessoires
VSM Etat initial Planification Réunion pluridisciplinaire Liste des patients pour traitement intracrânien Décision du traitement Centre partenaire Date du premier traitement Le patient vient pour la séance de simulation et les séances de traitement Au centre partenaire Pose des marqueurs 45 min Imagerie 1 heure Contourage 2 heures Le patient a reçu l’ensemble du traitement Dosimétrie 0,5 à 3 jours Validation 1 heure Réalisation des accessoires 4 heures Contrôle Qualité 1 heure/ch. Simulation 45 min Séance de traitement 25 min/ch. Au CPO The decision for treatment is made during a multi-disciplinary staff meeting (which is called the staff, even in French), then the process can begin. During this meeting, the date of first treatment is also fixed. Some acitvities are performed at the partner center. Markers are implanted in patient skull and constitute references necessary to check if the patient is in the right position during treatment. Medical imaging (MRI imaging and CT scan) is necessary for Treatment planning operators determined the ballistic of irradiation, that is the number of field that will be delivered to the patient for each treatment session, their orientation and the dose of proton required for each field. After a validation by physicists and oncologists, custom accessories need to be manufactured in the internal manufacturing workshop. Those accessories will give the right shape to the irradiation field, so that the tumor will be perfectly covered and reached at the right depth.. Then, after a quality control for each field dosimetry and accessories, a simulation phase is performed. The objective is to ensure that the restraint system and the accessories will permit to verify that the paitent stays immobile during setup and treatment. Then, the treatment can begin. Each treatment session has two phases: the setup phase that represent 90% of the duration and during which radiological technologists put the patient in the right position. The second phase is the treatment in itself and length for only few minutes. Going from one step to another is not immediate. Between each process step, in the process map, we add triangles that represent the waiting time before a patient or a patient file can be processed. Those times and the processing time at each step allow to evaluate the total lead time between the decision of treatment and the first treatment session, which is more than 12 weeks. The mapping phase is crucial in lean methology to understand the process, study the delays, identify critical resources and opportunities to improvement. This led to identify 4 main kaizen workshops. For each Kaizen workshop a multi-disciplinary group has been set up to analyze the problem, propose and implement solutions. In the following, I will make a focus on one of the workshop which dealt with treatment time optimization. Reflexions on future state include: what is the takt time, = the available working time per day devided by the demande rate? In the case of CPO, several takt times can be considered. How could we remove triangles In an ideal future state: Lead Time > 12 semaines Value Added Time < 1 semaine GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

9 Qui est le client? Qu’est ce que la valeur?
Acteur Rôle Attentes Le patient Reçoit le soin Délais courts, sécurité, confiance, respect du planning Le radio-oncologue Prescrit le soin File d’attente réduite, efficacité, maîtrise des risques L’assurance maladie Rétribue pour le soin (paye le CPO) Utilisation optimale des ressources, coûts de fonctionnement réduits GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

10 VA vs. Non VA Activités à valeur ajoutée,  contribuent à transformer un produit ou à délivrer un service ou un soin Activités à non valeur ajoutée apparente,  = gaspillages pourraient être éliminés sans dégrader la qualité du soin. Activités à non valeur ajoutée nécessaires mais pour lesquelles le « client » n’est pas prêt à payer. Phase d’irradiation au cours du traitement Fabrication des accessoires Déplacement inutile Recherche d’un outillage Dépend du point de vue et de la perception de la valeur Exemple de la simulation GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

11 Réalisation des accessoires
Planification Réunion pluridisciplinaire VSM Etat initial Analyse et chantiers Liste des patients pour traitement intracrânien Décision du traitement Centre partenaire Long délai Liste d’attente Planification du parcours patient Date du premier traitement Le patient vient pour la séance de simulation et les séances de traitement Au centre partenaire Pose des marqueurs 45 min Imagerie 1 heure Contourage 2 heures Le patient a reçu l’ensemble du traitement Réduction de la phase de simulation Activité à à non valeur ajoutée Dosimétrie 0,5 à 3 jours Validation 1 heure Réalisation des accessoires 4 heures Contrôle Qualité 1 heure/ch. Simulation 45 min Séance de traitement 25 min/field Au CPO The decision for treatment is made during a multi-disciplinary staff meeting (which is called the staff, even in French), then the process can begin. During this meeting, the date of first treatment is also fixed. Some acitvities are performed at the partner center. Markers are implanted in patient skull and constitute references necessary to check if the patient is in the right position during treatment. Medical imaging (MRI imaging and CT scan) is necessary for Treatment planning operators determined the ballistic of irradiation, that is the number of field that will be delivered to the patient for each treatment session, their orientation and the dose of proton required for each field. After a validation by physicists and oncologists, custom accessories need to be manufactured in the internal manufacturing workshop. Those accessories will give the right shape to the irradiation field, so that the tumor will be perfectly covered and reached at the right depth.. Then, after a quality control for each field dosimetry and accessories, a simulation phase is performed. The objective is to ensure that the restraint system and the accessories will permit to verify that the paitent stays immobile during setup and treatment. Then, the treatment can begin. Each treatment session has two phases: the setup phase that represent 90% of the duration and during which radiological technologists put the patient in the right position. The second phase is the treatment in itself and length for only few minutes. Going from one step to another is not immediate. Between each process step, in the process map, we add triangles that represent the waiting time before a patient or a patient file can be processed. Those times and the processing time at each step allow to evaluate the total lead time between the decision of treatment and the first treatment session, which is more than 12 weeks. The mapping phase is crucial in lean methology to understand the process, study the delays, identify critical resources and opportunities to improvement. This led to identify 4 main kaizen workshops. For each Kaizen workshop a multi-disciplinary group has been set up to analyze the problem, propose and implement solutions. In the following, I will make a focus on one of the workshop which dealt with treatment time optimization. Reflexions on future state include: what is the takt time, = the available working time per day devided by the demande rate? In the case of CPO, several takt times can be considered. How could we remove triangles In an ideal future state: Forte variabilité du temps de traitement Optimisation du temps de traitement Manque d’appro. Long délai 5-S Réimplantation Flux tirés Lead Time > 12 semaines Value Added Time < 1 semaine GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

12 Chantiers Kaizen : DMAIC
Définition du problème 4 chantiers principaux Réimplantation de l’atelier de mécanique et flux Réduction de la variabilité des durées de traitement Limitation de l’étape de Simulation Planification du parcours patient: le retro-planning Mise en place de mesures Analyse des données Identifcation des causes Elaboration de solutions Mise en place et contrôle GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

13 Résultats quantitatifs
2008 Délai de prise en charge: Nb traitements par jour: Salle Y1: 10 Nb séances annuelles: 4500 2007 Délai de prise en charge: Nb traitements par jour: Salle Y1: 8 Nb séances annuelles: 4000 Centre 1 Centre 2 Centre 3 8 semaines Centre 1 Centre 2 Centre 3 13,1 sem 12,4 sem 12 sem Processus mieux maîtrisés Responsabilisation des acteurs Mise à jour des faiblesses pour s’améliorer Meilleur ressenti du patient et du soignant : stabilité, maîtrise Deux heures /jour pour les tests du nouvel acccelérateur Amélioration locale: Enchaînement des processus: juste à temps: rétro planning Finally, what are the results of the project so far: delay for patient treatment has decreased to 8 weeks. Teams are able to welcome 2 more patients per day. In 2008, 4500 sessions have been provided. As other results, it is important to highlight that processes are now better known and better controlled. Autre résultats Journées STP du GDR MACS - Annecy 28/29 oct L.Trilling et Y. Jacquemin

14 Conclusion et perspectives
Leçon du projet La radiotherapie est une discipline où le Lean et le Six Sigma peuvent être appliqués et apportent des améliorations significatives Le CPO est devenu une organisation apprenante, ayant le réflexe de la résolution de problèmes. Prochains chantiers au CPO? Amélioration de la maintenance et Flexibilité des plannings Application du lean dans des structures de plus grande ampleur Besoin de formation et d’engagement du management Par où démarrer? Comment créer la dyamique? Elimination des gaspillages grâce aux outils mais Comment réduire la variabilité ? i.e. déviation par rapport à un standard: comment définir ce standard? Comment assouplir les rigidité ? Comment introduire de la flexibilité? Getting people to think and get initatives is the key Improvement from the patient, the staff and the management point of vue. lean and six sigma methodologies objectives are to reduce wastes, variability and rigididy, which are the main enemies t The main question is how to define a standard in health care organization, standardization is often a sensitive subject for professionals that will argue that each patient is different and follow a custom process. However, it worth trying to find the common part of each care provided to patient. This leads to talk about another barrier to performance improvement: the rigidities are related to the capacity of an organization to adapt and change way of working. This may be the main difficulty in Health care organizations: convince people that they can change their habits without damaging the quality of care. Small structure with ability to act quickly Larger structure, where the pressure to reduce expenses. GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

15 Merci pour votre attention

16 Example of Kaizen workshops Treatment session in treatment rooms
Objective: rataionaliser l’utilisation de la salle de traitement - Methodologie: DMAIC Définition du problème Variability in the treatment session time Mise en place de mesures Nb of treatments Analyse des données Time for 1 treatment Identifcation des causes Standard Tolerance Over limit The created working group involved physists, radiological technologist, supervisor, treatment planning operators Methodology DMAIC. The problem in treatment room is that the treatment time is variable. Too many treatment session duration exceed the standard (which is 25 minutes for the first fied, and 20 minutes for the subsequent one). The target situation would be reached if all the treatment sessions time are below a certain limit, with only occasional exception. Les outils de résolution de problème sont utilisés par les soignants. Oui ils sont capables de se les approprier. 25 minutes pour le premier champ 20 minutes pour les suivants Elaboration de solutions Situation intiale Situation cible Mise en place et contrôle GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

17 Example of Kaizen workshops Treatment session in treatment rooms
Objective: Streamline the use of treatment room - Methodology: DMAIC Define the problem Variability in the treatment session time Data gathering Identification of direct causes for deviation and criticality analysis (FMECA) Measure facts Analyse gathered data Identify root causes Then a measurement phase began. Data have been collected. When a treatment time exceed the standard, a cause for the deviation has been registered. Then, for each direct cause and criticality analysis has been performed thanks to Failure Mode and Effects cricicality analysis. Here we can see that the main cause for deviation is that the patient moves. If the patient moves, radiological technologists have to follow the set up protocol once again to ensure the patient stays in the good position during the treatment. But why does the patient moves? How to make sure he keeps the same position? Design improvement Implement and control GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

18 Example of Kaizen workshops Treatment session in treatment rooms
Objective: Streamline the use of treatment room - Methodology: DMAIC Define the problem Variability in the treatment session time Data gathering: set up and treatment duration Identification of direct causes for deviation and criticality analysis (FMECA) Measure facts Analyse gathered data Root cause analysis for most critical problems (Ishikawa, 5 Why) Brainstorming to find solutions (set up of an action plan) Follow-up of undesirable events Identify root causes For main causes, root cause analysis thanks to problem solving tools such as Ishikawa (or fish bone diagram), 5 whys and brainstorming were used to determine the original problem and the solutions that could be set up to solve the problem. A complete action plan has been established and implemented. After implementation, a system to follow-up undesirable events is necessary. Design improvement Implement and control GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

19 Analyse des causes racine
Manque d’information Consultation paramedicale Here is the whole Fish Bone diagram where you can see all the causes of the problem and solutions. For exemple, the patient moves because he does not remember the intructions given during the first consultation. A solution to this particular issue could be to organize a paramedical consultation to recall instructions and make sure the patient understands and is stressless. Some other workshops have been developped: manufacturing workshop, simulation reduction. GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

20 Les différentes phases du traitement après la réunion de concertation pluridisciplinaire ou staff
Imagerie et contourage Dosimétrie (Treatment planning) Pose des marqueurs IRM et Scanner au centre partenaire Superposition des images Définition des passages autorisés et interdits Déterminer la dose à émettre à chaque séance Définir le nombre et l’orientation des champs Références pour le positionnent Visible sur clichés Positionnement et traitement Accessoires et simulation Mise en place du patient Vérification de la position Contrôle durant l’irradiation Irradiation de la lésion (Patient traité en 30 séances environ) Création des équipements Condition de référence RCP: réunion concertation pluridisciplinaire Redaction cr envoyé aux centre Le centre programme l’irm (prend du temps, délai d’accès aux irm très long: la radiothérapie a des créneaux dédiés ex/ 2h par semaine, si le creneau est loupé…) Pose de billes dans le crâne par un chir du centre, scanner, irm par le centre Superposition des images et contourage (= définir les passages autorisés et interdits des faisceaux pour protéger les organes à risque) Dosimétrie ou treatment planning: déterminer la dose à émettre à chaque séance (25 min) pour traiter au mieux la tumeur sans abimer les tissus sains. L’orientation des champs doit aussi être définie de manière à assurer la précision requise (1 mm). Création des équipements, contrôle qualité et simulation (avec le patient: vérification des positions des accessoires, faisabilité de mise en place du patient) Début de traitement GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

21 Le contexte de la radiothérapie
Modalité thérapeutique majeure du traitement des cancers (40 % des traitements) cas par an en France Nombreuses similitudes avec la problématique de production : Utilisation d’un équipement de haute technicité (fourniture industrielle) Répétition de séances de traitement (~30 par patient, 1 par jour habituellement) La structure d’une séance suit un protocole Discipline en pleine évolution (réduction des marges, précision, traitements dynamiques) augmentation du risque si le processus n’est pas bien maîtrisé ressources limitées mais une demande très forte besoin de méthodologie pour une démarche de progrès La radiothérapie est une méthode de traitement locorégional des cancers, utilisant des radiations pour détruire les cellules cancéreuses en bloquant leur capacité à se multiplier. L'irradiation a pour but de détruire toutes les cellules tumorales tout en épargnant les tissus sains périphériques. La radiothérapie est utilisée chez plus de la moitié des patients ayant un cancer. Elle est, avec la chirurgie, le traitement le plus fréquent des cancers et peut entraîner une guérison à elle seule. GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

22 VSM Etat initial Centre partenaire Long délai
Liste des patients pour traitement intracrânien Décision du traitement Centre partenaire Long délai Liste d’attente Planification du parcours patient Date du premier traitement Le patient vient pour la séance de simulation et les séances de traitement Au centre partenaire Implantation marqueurs 45 min Imagerie médciale 1 heure Contourage 2 heures Le patient a reçu l’ensemble du traitement Réduction des activités à “NVA” Activité à à non valeur ajourée 1-5 d Planification du traitement 0,5 à 3 jours Validation 1 heure Réalisation des accessoires 4 heures Contrôle Qualité Control 1 heure/ch. Simulation 45 min Séance de traitement 25 min/field Au CPO The decision for treatment is made during a multi-disciplinary staff meeting (which is called the staff, even in French), then the process can begin. During this meeting, the date of first treatment is also fixed. Some acitvities are performed at the partner center. Markers are implanted in patient skull and constitute references necessary to check if the patient is in the right position during treatment. Medical imaging (MRI imaging and CT scan) is necessary for Treatment planning operators determined the ballistic of irradiation, that is the number of field that will be delivered to the patient for each treatment session, their orientation and the dose of proton required for each field. After a validation by physicists and oncologists, custom accessories need to be manufactured in the internal manufacturing workshop. Those accessories will give the right shape to the irradiation field, so that the tumor will be perfectly covered and reached at the right depth.. Then, after a quality control for each field dosimetry and accessories, a simulation phase is performed. The objective is to ensure that the restraint system and the accessories will permit to verify that the paitent stays immobile during setup and treatment. Then, the treatment can begin. Each treatment session has two phases: the setup phase that represent 90% of the duration and during which radiological technologists put the patient in the right position. The second phase is the treatment in itself and length for only few minutes. Going from one step to another is not immediate. Between each process step, in the process map, we add triangles that represent the waiting time before a patient or a patient file can be processed. Those times and the processing time at each step allow to evaluate the total lead time between the decision of treatment and the first treatment session, which is more than 12 weeks. The mapping phase is crucial in lean methology to understand the process, study the delays, identify critical resources and opportunities to improvement. This led to identify 4 main kaizen workshops. For each Kaizen workshop a multi-disciplinary group has been set up to analyze the problem, propose and implement solutions. In the following, I will make a focus on one of the workshop which dealt with treatment time optimization. Reflexions on future state include: what is the takt time, = the available working time per day devided by the demande rate? In the case of CPO, several takt times can be considered. How could we remove triangles In an ideal future state: Forte variabilité du temps de traitement Optimisation du temps de traitement Manque d’appro. Long délai 5-S Réimplantation Flux tirés Lead Time > 12 semaines Value Added Time < 1 semaine GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.

23 Current state VSM Scheduling of patient route
Reduction of NVA activities Treatment time optimization 5-S Layout Reconfiguration Pull system Modélisation du processus complet: De la décision au traitement Basé sur les données réelles Objectifs : Lisser la charge Réduire le temps de prise en charge (pédiatrie)=> flux tendu Améliorer qualité et capacité de traitement Lead Time > 12 weeks Value Added Time < 1 week GISEH CHU Clermont Ferrand 2-4 sept 2010 L.Trilling et al.