May 28 – 30, 2015, Montréal, Québec Demystify the LEAN approach Justine St-Onge t.i.m. IUCPQ

Disclosure Statement: No Conflict of Interest May 28 – 30, 2015, Montréal, Québec I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization. I have no conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships). I have no financial relationship or advisory role with pharmaceutical or device-making companies, or CME provider. I will be discussing the results of ____ (“off-label” use), which is currently classified by Health Canada as investigational for the intended use. I will not discuss or describe in my presentation at the meeting the investigational or unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

May 28 – 30, 2015, Montréal, Québec Disclosure Statement: With a Conflict of Interest I have/had an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization, which could include: Examples: having received a grant(s) or an honorarium from a commercial organization. holding a patent for a product referred to in the CME/CPD program or that is marketed by a commercial organization. holding investments in a pharmaceutical organization, medical devices company or communications firm. currently participating in or have participated in a clinical trial within the past two years. I intend to make therapeutic recommendations for medications that have not received regulatory approval (i.e. "off-label" use of medication).

Presentation plan  What’s your situation ?  History  Explanation  Current context  Debate  Conclusion

What do you know about LEAN Healthcare ?  Who has heard about LEAN Healthcare?  What do you think of it ?  Who was part of a LEAN Healthcare project ?  Good or bad experience ?

Introduction  Growing popularity  Several controversies  Preconceptions  Different names over the years  Is it justified ?

History Frederick Taylor  Beginning of 20 th century  Scientific work organisation  Taylorism  Scientific perspective  Scientific management  Engineers  Time and motion studies  Science = guide !

Many different names :  Total quality management  Quality circles  Business process reengineering  Six Sigma  LEAN  LEAN healthcare History

LEAN Healthcare Purpose :  Avoid waste  Eliminate interruptions  Reduce variations  Increase the « plus value »  Eliminate errors

How does it work ? 1. Define what needs to be improved 2. Identify the problems 3. Analyze the possible solutions 4. Select solutions 5. Apply solutions 6. Follow up

1. Define what needs to be improved  Do not take the whole thing  Divide the work  Ex. One exam at the time  Establish limits

KAIZEN  Three day deliberation Composition  Guide - Moderator  Department members  Managers  External actors (if needed) 2. Identify the problems

1 st day IIdeal world BBrainwriting + logic tree diagram SSpaghetti diagram VValue stream mapping IIdentification and priorization

1 st day IIdeal world BBrainwriting + logic tree diagram SSpaghetti diagram VValue stream mapping IIdentification and priorization

1 st day IIdeal world BBrainwriting + logic tree diagram SSpaghetti diagram VValue stream mapping IIdentification and priorization

1 st day IIdeal world BBrainwriting + logic tree diagram SSpaghetti diagram VValue stream mapping IIdentification and priorization

2. Identifier les problèmes

2. Identify the problems 1 st day IIdeal world BBrainwriting + logic tree diagram SSpaghetti diagram VValue stream mapping IIdentification and priorization

3. Analyze the possible solutions 2 nd day  Group discussion  Cause argument  Say everything we think about  Do not reject any idea  Moderator  Don’t let deviate from subject

4. Select solutions 2 nd day  Suggest possible solutions  Value stream mapping 3rd day  Identify the solutions  Create a timeline  Choose LEAN tools  Get manager’s approval

4. Select solutions Tools  5 S

4. Select solutions

4. Select solutions  5 S  Loi de Little  Kanban

4. Select solutions

4. Select solutions  5 S  Loi de Little  Kanban  Poka-Yoke

4. Select solutions

4. Select solutions  5 S  Loi de Little  Kanban  Poka-Yoke  SMED  Takt time  3 P  Spaghetti diagram  Theory of constaints  Standard work  Visual management

5. Apply solutions  Apply immediatly the solutions  Train colleagues  Involve everyone  Do not let it go  Be proactive  Make changes when needed  Remain critical

6. Follow up  Create commitees  Make people in charge  Do not let it go  Maintain motivation

In our reality, is LEAN Healthcare justified ?

L’APTS se retire des projets Lean dans le réseau de la santé et des services sociaux - 20 avril 2015 «Nos membres voient bien que la méthode Lean n’est pas utilisée pour améliorer leur travail au quotidien, indique la présidente de l’APTS, Carolle Dubé. Depuis l’implantation, ils vivent plus d’épuisement professionnel en raison de l’alourdissement de leurs tâches, de détresse psychologique liée à la pression à la performance et la partie patronale est de moins en moins transparente. Pire encore, certains gestionnaires utilisent cette méthode pour justifier des compressions budgétaires et abolir des postes. L’APTS ne peut pas accepter la réduction des services à la population.»

What are the causes ?

Orders from the top  Top-down  Use of external firms « Si les changements dans un environnement de travail peuvent causer de la résistance de la part des employés, il semble que cela n’ait pas été le cas à l’hôpital Anna-Laberge. “Le projet est parti avec les gens du milieu. Ce sont les infirmières et les médecins qui nous ont suggéré des manières d’améliorer l’efficacité du travail », indique Dre Fréchette.

No power to workers  Workers have nothing to say in the process  Imposition of new methods […] n’écoute pas les pistes de solutions proposées par les ergothérapeutes, les physiothérapeutes, les travailleuses sociales, les techniciennes en travail social, les thérapeutes en réadaptation physique et les agentes de relations humaines représentés par l’APTS et directement impliqués dans les services à domicile auprès de la population. Pourtant, ce sont ces professionnels qui connaissent le mieux la réalité du terrain.

Use of statistics  Look good because of statistics  Forget the importance of certain tasks « Par exemple, afin de faciliter l’intégration scolaire d’un enfant atteint de paralysie cérébrale, l’ergothérapeute devra, entre autres, contacter la commission scolaire afin de l’aviser de l’arrivée de l’enfant et faire de la recherche pour trouver les équipements adaptés les plus adéquats (chaise, bureau, etc.) pour l’enfant. »

Rigid application  Not a factory  Quality service  Unpredictable work « Sa méthode consiste à créer une grille de planification sur laquelle tous les actes, allant de l'administration d'un gavage à une intervention psychosociale, sont minutés. À titre d'exemple, le lavage d'une oreille par une infirmière devrait prendre 15 minutes. Deux oreilles: 20 minutes. Un soin de plaies simple ne devrait pas prendre plus de 15 minutes. »

What do YOU think ?

 If the project is well controlled, is it a good method to use ?  Do you think we should move on to something new ?  Is our healthcare system too much bureaucratic ?

Conclusion  LEAN ≠ revolution  Effective bottom-top  Certain limits  Unpredictable work

Thanks ! Nancy Boily coordonnatrice administrative imagerie médicale IUCPQ

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