Focus and Leverage Part 179

Beginning January 7^th I will be leading a team of hospital employees working on a problem in the Emergency Department (ED) of their hospital.  There is a metric that is tracked which measures the length of time from when the patient enters the Emergency Department until the medical screening exam begins by the physician known as “Door to Doc” time.  The problem is that under the new Healthcare “rules,” if the wait times are too long, then patient satisfaction scores will be negatively impacted.  If patient satisfaction scores are too low, then Medicare, Medicaid and private payers like Blue Cross and Aetna will reimburse for services at a much reduced rate.  Door to Doc time is but one facet of patient satisfaction, but it’s important from a patient satisfaction perspective.

Since 1986, with the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), patient volumes in emergency departments have increased significantly.  Several different studies have estimated the increase to be on the order of 40%.  Because of this increase, overcrowding and excessive wait times have forced EDs to look at their processes to improve flow and reduce wait time.  They’ve also been forced to provide more complex and prolonged care to the point where sometimes ED patient’s health is at risk. Because this new higher level of ED patients is straining the ED staff’s ability to handle them in a timely manner and to provide timely and quality care.  As a result, even more delays are being experienced by the incoming patients.

In anticipation of our improvement event, the team leaders are busy collecting and analyzing pertinent baseline data to be used by the full team to make improvements to patient flow and satisfaction.  As I’ve written about many times in my blog, the problem to be studied is correlated with the actual throughput rate of patients passing through the Emergency Department.  It should be clear now to all of my regular readers that the path this team will take will be to first, understand the boundaries of our improvement effort and performance metrics we are trying to improve.  This will be accomplished by reviewing the project charter that was created by the project champion.  Once this is completed, the two Green Belts and I will deliver “just in time training” to the full team so that the concepts of things like process, constraints management, waste categories and the improvement tools we will use during our improvement initiative will be clearly understood.

The team will then “walk the Gemba” so they have the information needed to create a SIPOC diagram and a current state process map (or Value Stream Map).  The team will observe things like patient flow, estimated processing times, where apparent waste exists, key hand-offs within this process, paper work, wait times, patient queues, etc..  They will use all of this information to correctly identify the constraint within the Emergency Department’s process from point of entry to the beginning of the examination by the ED physician.

The team’s next step will be to decide how to exploit the constraint by looking for ways to reduce waste and variation within it by employing the principles of Lean and Six Sigma.  The key to improving patient flow will be to identify and focus the team’s improvement efforts primarily on the system constraint, but will also look for ways to reduce things like the number of handoffs, improve current communication mechanisms, waiting room times, etc. during our effort.

There is an inherent danger in isolating our improvement effort to only this specific part of this process  (i.e. Door to Doc).  By limiting our “field of view” to this single part of the patient value stream, we could create downstream problems. Improving one part of a process will most surely improve the flow through the current constraint, but a new constraint will arise as an effect of the improvement effort.  For example, when the team is successful in reducing the Door to Doc time, the velocity of patients moving to the next step in the process will be higher and could cause a queue of patients waiting for things like test results to come back or even the physician’s decision on whether or not to admit the patient.  If the decision is made to admit the patient, then the new constraint could even be the discharge process that frees up beds in the various hospital units.  In the world of TOC, improving a singular part of the process without considering the overall impact on the total system is known as a localized improvement.

Once the Gemba Walk has been completed we will develop a SIPOC to get a 10,000 foot view of our process.  When we are satisfied with our SIPOC we will then create a Current State Process Map with swim lanes listing all of the activities used to move a patient through this process.  The team will then perform a value stream analysis by color coding each activity in the process as either value-added (Green), non-value-added but necessary (yellow) or non-value-added (red).  We will then create an ideal state map by removing all of the non-value-added activities.  Finally, we will create a future state map that will lie somewhere in between the current state and the ideal state maps.  The future state map will identify all of the needed changes to the current process and should significantly improve the flow through the door to doc process.

The final stage of our improvement effort will be to develop an improvement plan, based upon how we see our future state process.  The plan will consist of Just Do Its, potential Rapid Improvement Workshops that might be needed as a result of this new process, potential additional Value Stream Analyses recommendations and possible DMAIC opportunities needed to reduce variation.  The Just Do Its will typically be tied directly to the creation of the team’s recommended Future State Process Map.  The team will then present their findings and recommendations to the executive staff and process owner(s) to gain their buy-in.

It should be a “fun” week and when it’s completed I will report the team’s findings and recommendations here on my blog.

Bob Sproull

Focus and Leverage Part 178

2012 has been an interesting year for me.  I have made the transition from primarily serving the Aviation Maintenance industry to the healthcare field and I must say I’m very happy I made the shift.  That’s not to say that I didn’t enjoy the aviation work because I totally did.  In fact, given the opportunity I would go back and help companies maintain military vehicles especially those working within the Department of Defense.  It’s clear to me that all governmental departments in this country and many others need to change their focus to learn how to do much more with much less.  As the politicians haggle over spending cuts and tax increases, most don’t understand how to identify and focus on the right areas.

My blog is called focus and leverage for a reason.  It doesn’t matter whether we’re talking about a manufacturing company, a hospital or a governmental agency.  There is a constraint that is limiting their overall performance and unless and until it is identified improvement efforts will simply not be as good as it could or should be.  I’ve been fortunate enough in my career to work in a variety of industries and they all share the common need to identify the system constraint, exploit it and then subordinate everything else to it.  In a manufacturing system or hospital or governmental agency or any other industry it’s all about optimizing flow.  Enhancing the flow or throughput of products, patients or maintained military vehicles all boils down to locating the constraint and ultimately breaking it.

If you’ve ever been in a hospital emergency room or have had to wait for your turn to have a surgical procedure or even received outpatient treatment, you have no doubt experienced an inordinate amount of delays.  In all three cases, there is a single point in all of these processes that causes these wait times.  If the hospital wants to reduce these delays, and they all will once the Affordable Care Act is totally implemented, then the only way to do so is to identify that part of the process that causes the delays (i.e. the constraint).  Once it’s identified, it must be exploited by eliminating (or reducing) the non-value-added waste that most certainly exists.  Attempting to eliminate waste in a non-constraint is, in my opinion, wasted effort.  Yes your efforts will reduce waste, but it won’t reduce the flow time or improve the rate at which patients flow through the hospital processes.  In like manner, if you’re trying to improve the number of say, aircraft through a maintenance process, you must find the reason why you’re falling short of the number required.  And like hospital processes, attempting to improve a non-constraint processing steps won’t help you improve throughput.

In many, many cases (as high as 90%) the constraint is not a physical process step at all that is causing the process to be slower than it should be, but rather an existing policy or other requirement in place.  It might be something as simple as an approval requirement that must be completed prior to work being initiated.  Sometimes in a union environment it could be a job classification that prevents you from performing a simple task.  The key to breaking a policy constraint is to use logic and common sense to eliminate the impediment to improved flow.  By that I mean by simply understanding the policy in common sense terms an alternative procedure can be put in place.  There are tools within the Theory of Constraints toolkit that are designed to break these types of conflicts.  The most popular of these is the Conflict Resolution Diagram or Conflict Cloud or Evaporating Cloud as it is known.  The key to using these tools is to clearly identify and define the conflict, surface the assumptions behind the conflict and then develop injections that break the conflict.

In the coming weeks I’ll report on the tools of TOC that will help everyone improve the flow of processes.  Since I have transitioned to healthcare, much of what I’ll report on will be from the healthcare industry.  Happy New Year everyone!!!

Bob Sproull

Happy Holidays

As 2012 ends I wanted to wish all of my followers a very happy holiday season with hopes that 2013 will be a fantastic year for everyone.  Bruce and I are working on the sequel to Epiphanized and will no doubt release it in 2013.  It is our hope that the sequel will appeal to a much wider audience since we plan on incorporating chapters on healthcare, maintenance, manufacturing and other areas of interest.  Our plan is to introduce new improvement tools as well as new ways to use existing ones.  We'll have new characters as well as Joe, Connor, Sam and Becky that you met in Epiphanized.  Thanks to everyone who has followed Focus and Leverage for the past 3 years as Bruce and I have truly enjoyed writing it.

Bob and Bruce

Focus and Leverage Part 177

In my last posting we discussed two examples of why it’s so important to look at the entire process rather than isolated parts.  If we don’t do this, we could end up with a localized improvement that could have a negative effect on other parts of the process.  Today I want to discuss this same situation and how it could negatively impact the next step in this particular process.  Once again this is a healthcare example that I was personally involved with.

This scenario took place in a Radiology Department of a hospital in the Chicago area.  When the project charter was written, I questioned its scope because what they had chosen to improve was a middle part of the process in question.  Specifically the Champion had elected to improve the part of the process from registration being completed to the start of the radiologic exam.  In addition, the Champion had limited the process to CT Scans, only one of many test that were routinely done in this part of the process.  My concern was that if only this part of the process was improved, and I had no doubt that it would be, then patients would end up being “pushed” to the exam area creating an excessive queue of patients waiting to be tested.  My concern was heard and considered, but in the end the leadership decided to continue on with their original charter scope.

The team leader’s first order of business was to review the project charter with the embers of the team, making sure they understood the boundaries of the process being studied and the targets this team was supposed to achieve.  The team reviewed existing cycle time data and found that, on average, the time required from registration complete to exam start was 26 minutes with the goal set by the project champion being .15 minutes.  The team received our customary training in the basics of Lean, Six Sigma and Constraints Management and began the hard work to reduce the cycle time by nearly 50% (i.e. 26 to 15 minutes).

The team chose to walk the process to better understand its flow and to gather any potentially meaningful information.  This information would be used later to create a current state process map of the process from registration being completed to the start of the patient’s CT exam.  The team noted that even though the process was relatively simple in nature, there were still two separate waiting rooms.  This observation would become an interesting and useful bit of information.  The team next created a SIPOC Diagram to better understand the process flow from a high level.  Based upon the estimated times collected during the Gemba Walk, the team determined that the patients actually spent a total of 19 minutes between the two waiting rooms.  Because patient satisfaction was another important performance metric, it was clear to the team that the extended waiting room times was an important factor to consider as they designed a future state.  Figure 1 is their SIPOC which has both the original estimated times and what they believed their future state could be.  The team used the SIPOC to identify their system constraint and worked to remove time from it.

Figure 1

Using the current state process map, the team then completed a value stream analysis and color-code each step as either green (value-added), red (non-value-added) or yellow (non-value-added but necessary).  The team then created their ideal state map by eliminating all steps that didn’t add value which theoretically reduced the average process time from twenty-six minutes to about seven minutes.  They then created a future state map which came in with a cycle time of just under 12 minutes.  Even though they had met their project target of less than 15 minutes, the team understood that they had made a localized improvement that could have a negative impact on patient satisfaction.  Their concern was that the constraint had probably moved to the actual exam and that by reducing the processing time, the number of patients entering the exam areas would probably increase.

Figure 2 is the team’s current state Process Map after completing their value stream analysis and as you can see there were 18 activities coded red as non-value-added (NVA), 6 non-value-added but necessary, coded as yellow and only 6 value-added (VA) activities coded as green.

Figure 2

Figure 3 is the Ideal State developed by the team and Figure 4 is their future state map.

 Figure 3

Figure 4

In Figure 4 you’ll see that there were 0 reds, 5 yellows and 7 greens.  The anticipated cycle time improvement moves from 26 minutes to only 12 minutes.  One of the most noticeable difference is the complete elimination of one of the two waiting rooms which should have a positive impact on patient satisfaction.

As the team implements their future state recommendations, I’ll follow their project and see if their concern was valid or not.  No matter what, this team now understands the potential danger of making localized improvements without considering the possible negative impact on the system.

Bob Sproull

Posting for Focus and Leverage Part 173

Thanks to Paul Merino, who sent me a link on how to delete unwanted comments, I don't have to delete posting 173.  Thanks very much Paul!!

Bob

Posting 173

For those of you who regularly read my blog postings, posting Focus and Leverage Part 173 has some very negative links attached to comments, so please do not click on them.  I sincerely apologize for the links put on this posting by some anonymous person!!  In the end, this anonymous person obviously has no respect for people or for blog postings and in the end, I may have to delete this posting.  Again, please accept my apologies.
Bob Sproull

Focus and Leverage Part 176

These days it is difficult to turn on our televisions without hearing something about healthcare and with the impending Affordable Healthcare Act set to sweep into our lives just weeks from now, we will hear even more.  Healthcare professionals openly express the fact that they must improve their ability to deliver high quality services.  The fact is, people now have choices as to which healthcare provider they elect to use and their choices are based upon a variety of factors, not the least of which is how much “wait time” they will tolerate.  Because of this, numerous consultancies have sprung up, all claiming to be able to improve the delivery of healthcare services.  The problem is, many of these groups fail to identify the core problems and end up treating the symptoms (excuse the pun) rather than identifying and treating the true root cause of the organizational problems.

One of the glaring problems that I see with many healthcare consultants is the failure to consider the impact of their localized improvements on the overall healthcare system.  Improvements are made in one area which can cause sometimes devastating negative effects in another.  Consider the following:

·         A team determined that there was a problem with the flow rate of patients entering a hospital Emergency Department (ED).  They identified the need to “speed up” the time from patient registration until the patient was admitted to the appropriate hospital unit.  The team was very successful and reduced the time by nearly 50%!  This effort was hailed as a major success and rightfully so.  However, because the team hadn’t included the discharge process, patients ended up spending too much time on gurneys in hallways because there were no beds available.  This “effect” resulted in a rapid and significant deterioration of patient satisfaction scores.  The team had made a localized improvement without considering the potential impact on downstream processes.  If the team would have completed a system’s analysis, they could have predicted this negative result and quite possibly have studied and improved the discharge process before attempting to improve the flow through the ED.

·    A team was commissioned to improve an Operating Room’s (OR) ability to increase the number of surgeries performed.  The team determined that by improving the throughput of the OR, without adding additional staff, most of the new revenue should flow directly to the hospital’s bottom line.  The team worked feverishly and was quite successful as the throughput of the OR improved by nearly 40%.  What a great achievement and it was hailed as a major success!!  The only problem was that this facility did not have enough staff or beds in their post-operative department (ICU) to handle this new volume of patients.  This failure to consider the possible impact on ICU resulted in the need to call in staff on very short notice, the need to hire additional staff, and OR patients spending too much time in hallways while beds were freed up.  The morale within ICU suffered and the hospital incurred significant additional operating expense (new hires) and just like the ED example, patient satisfaction scores took a negative hit.

Unfortunately, the failure to consider these obvious systemic effects, in favor of localized improvements, is an all too common practice in many hospitals and healthcare facilities.  This practice is a classic example of a silo mentality. The question becomes then, how do healthcare facilities avoid these problems?

Let’s look at both scenarios (i.e. Hospital Emergency Department and Surgical Unit) to better understand the high-level flow of patients in each.

Figure 1

Per Figure 1, the patient enters the Emergency Department, registers, and then is evaluated by the doctor.  The doctor then makes a decision regarding whether to treat the patient in the ED or admit the patient into a hospital unit.  In the case of the doctor deciding to admit the patient, there must be a bed available for the patient.  In the case of treating the patient in the ED, the impact on other functional areas within the hospital is not affected.

Suppose an improvement team is commissioned to reduce the time the patient spends in the ED.  If the team only looks at the actions taken in the ED (i.e. localized improvements) without considering the impact on the healthcare system, there will be a negative impact on the receiving hospital units.  Per my earlier example, if the team significantly increases the hospital admitting rate, then what impact might we see?  One impact is that beds might not be available for incoming patients.  Like our earlier example, incoming patients might spend an inordinate amount of time on a gurney in a hallway because no beds were available.  Do you think patient satisfaction would be negatively impacted?

So what should have happened before this improvement team was commissioned?  My recommendation would have been to study the discharge process first in anticipation of an increased load of admitted patients.  By studying and improving the discharge process first, the negative impact on patient satisfaction scores could have been completely avoided.  What should have happened was commissioning a team to improve the discharge process prior to improvements in the ED flow rate.  In other words, by looking at the overall process to get the improvement sequence correct, the patient satisfaction scores might not have suffered.

In the case of the team that improved the flow of patients into and out of surgery, the same scenario is seen in Figure 2.  The patient is first scheduled for surgery, is prepped and then has the surgery.  When the surgery is completed, the patient is transferred to a post-operative unit where they are evaluated, treated and eventually discharged.

Figure 2

Like the ED example, if the improvement team does not consider the downstream process steps (i.e. both post-operative unit and discharge process), a negative effect will be felt in the post-operative unit (ICU).  Once again, the discharge process should have been improved first, then the receiving unit (i.e. post-operative care unit), before improvements were made to the surgical unit.  In other words, improvements made in isolation (i.e. silo mentality) WILL result in negative effects down-stream (and sometimes up-stream).

In the next several postings we will continue to address problems associated with not considering the system impact as well as other healthcare issues that must be addressed.

Bob Sproull

Another Review of Epiphanized

Here is another review of Bruce and my book Epiphanized and although it is our first one that didn't rise to the level of a 5 Star like all of the rest did, the author still recommends our book to other readers.  From Bruce and I, thank you so much for taking the time to write this review.

Bob and Bruce

4.0 out of 5 stars Epiphanized it's easy to read and has a good story behind the main message - The application of TOC mainly, with Lean and 6Sigma, December 10, 2012

By 

Luis Cristovao (Azeitão, Setubal Portugal) - See all my reviews

Amazon Verified Purchase(What's this?)

This review is from: Epiphanized: Integrating Theory of Constraints, Lean and Six Sigma (Kindle Edition)

Epiphanized is a business novel format, in the tradition of Goldratt and other TOC authors. It has a good story rich of characters and companies, and has so many people involved that the authors "forgot" some of the characters like "The Quality Director" in the middle of the story.

The format is simple and straight and goes right away to the point considering TOC as the main drive to improvement. This is correct to me but is so direct that sometimes it seems unreal, because people resist more to change than what the novel show us.

With TOC, comes in Lean and 6Sigma but with somehow less detail, and I can understand this because otherwise the book would become very tedious and difficult to read.
The main points are there with this simplifications in mind and so it's very pleasant to follow the story.

In terms of TOC the final chapters with the CCPM explanation to me were the best part of the book cause it goes to implementation details.

In the end the appendixes on TOC, Lean and 6Sigma(TLS) are unusual in this type of novel format but are very well welcome and add value to the book.  So for the beginner of TLS and for the "not so beginner" (and maybe for the expert) I would recomend this book.

Focus and Leverage Part 175

In my last posting I discussed how two of the new recently trained Green Belts in the Chicago area healthcare facility used two newly learned improvement tools, namely the Process Map (with swim lanes) and a Value Stream Analysis to solve a lingering problem.  I also spent an inordinate amount of time describing another tool, the Interference Diagram and how it can be used to exploit a system constraint.  In this posting I want to discuss how two another two Green Belts used this tool to help stimulate their team, who was sort of stuck in the mud, move toward a solution to a problem that they had been working on.

These two Green Belts had been working on a project in the Post-Anesthesia Care Unit (PACU) at this facility and although they were making progress, they needed something that would stimulate the team to bigger and better things.  Maybe some new improvement tool would do the trick?  And when both of these Green Belts saw the Interference Diagram for the first time, they both knew that this tool could help them inspire their team to move in a new direction.  The team met shortly after their training and developed their own version of the Interference Diagram.

 

 

 

Figure 1

Figure 1 is the Interference Diagram (ID) that this team developed and as you can see, the Goal, or what this team wanted more of, was to be able to move this patient out of the Post Anesthesia Care Unit (PACU) much faster than they had been doing primarily because they needed the room for incoming patients and they had a limited number of beds that new patients could occupy.

If you remember my last posting, I told you that the items in the boxes surrounding the goal are the interferences or barriers that hold you back from achieving more of what you want.  This team has identified nine (9) barriers or areas for improvement and one-by-one their job now is to eliminate them altogether or reduce the effects of each interference.  The team’s conclusion was that these interferences, to one degree or another, all contribute to the extended time that patients remain in the Post Anesthesia Care Unit making the patient stay longer than it should be.  Their team’s mission now is to brainstorm solutions for each interference and then design a new process that will either eliminate the interferences or significantly reduce their impact.

The team still needs to estimate just how much time each of these interferences account for to determine the impact on the throughput of patients into and out of this unit.  As a result of the use of this ID, there is now a desire and need to run a full-blown project such as a Value Steam Analysis or Rapid Improvement event which will hopefully be scheduled and completed sometime in January.  I will meet with these two team leaders this week to discuss how best to approach this new initiative.  When the team completes this improvement effort, I will report on it here.  But one thing is for certain….these two new Green Belts and their team members are absolutely sold on this new tool.

Bob Sproull

           

Focus and Leverage Part 174

In my last posting I presented the framework for a consulting engagement in the healthcare field.  I finished that posting by saying that several of the new Green Belt graduates had taken what they had learned from the training and applied it to their own work environment.  In today’s posting I want to explain what these students had done with their training as well as part of their outcomes.  One thing I told the students during their “graduation ceremony” was to take their new tools and make them their own.  My concern has always been that when people learn a new tool or technique that they believe it can only be used as intended.  This is far from the truth because if this were the case, then new ways to use these tools and techniques would never be discovered and shared.  This posting is rather lengthy, but I felt compelled to provide our new readers some background information on one of the improvement tools…..the Interference Diagram.

Two of the Green Belt students had been working with a team on a flow issue within the facility and had really gotten nowhere in several months.  After they finished their training the team had a regularly scheduled meeting and the two students worked with the team leader to create a current state process map of a requisition to payment process.  This was an important step because for the first time ever the entire team could now visualize the entire process from beginning to end.  They spent quite a bit of time reviewing what they had constructed and then categorized each step as either value-added (green dots), non-value added (red dots) or non-value added but necessary (yellow dots).  Based upon the results of this value analysis, the team identified the system constraint and then used their training to construct a future state process map. Upon completion of the future state map the team immediately realized that they could remove five steps in the process.  These five steps required a significant amount of time to complete, so by simply mapping the process and identifying and exploiting the constraint, the team reached their cycle time reduction goal!

Last week I went back to this facility and delivered some additional training on a couple of other important tools……the Intermediate Objectives Map and the Interference Diagram.  I’ve written about both of these tools before on this blog, so you can review both of them if you’re new to my blog.  Two postings, Focus and Leverage Part 51 summarizes the IO Map while Focus and Leverage Part 57 discusses the Interference Diagram, although there are other postings for each one in this blog.  It is this last tool, the Interference Diagram that two of the new Green Belt students used to solve their problem.  But before I discuss what they did, let me summarize some key points in using the Interference Diagram for those new to this blog.

For those of us engaged in performance improvement initiatives there seems to be a constant bombardment of “things” that seem get in the way of what we’re trying to accomplish. Things that interfere with our attempts to achieve a goal or objective in our quest to make things better. Some of these things come out of nowhere in the name of uncertainty to stifle our efforts and still others are there just waiting to be found and acted upon. Wouldn’t it be great if there was a way, or at least a tool, to help visualize these “things” so that we could do something about them? Life would be so much easier wouldn’t it? Good news….such a tool does exist for identifying the myriad of business, production, healthcare and manufacturing issues that face us every day. It’s called an Interference Diagram (ID).

Most of you have probably never have seen or even heard of an ID before. Its origins date back to the mid-1990’s with Bob Fox and the TOC Center in New Haven, Connecticut. As a thinking tool it has not been well publicized and as such, is not well known. But just because it hasn’t been well publicized, don’t underestimate its importance from a problem solving perspective. The endearing qualities of the ID is that it’s both simple to learn and construct and is quite robust in its application. The ID is a thinking tool that offers the capacity to define and visualize those interferences or obstacles that block or hinder your ability to achieve a specific goal or outcome. It’s always far easier to define what we want, but much more difficult to define why we can’t have it and the ID helps us do that.  I use it often to exploit the system constraint after mapping the process to identify it.

The ID can be used at many different organizational levels to understand why things at all levels don’t happen or work the way we want them to. The ID can be used as a stand-alone tool or it can be used in conjunction with other tools, so its uses are multiple. As a stand-alone tool it provides a discrete analysis to better define and understand the obstacles that prevent accomplishment of our goal. But in a broader application it can be used to supplement the other, more common systems thinking tools developed by Dr. Goldratt as well as his Five Focusing Steps. No matter which way it is used, the end results can be very dynamic.

The Interference Diagram is quite simple to construct as depicted in Figure 1. The first step in its construction is to decide what it is you want more of or what your goal or objective is. When you’ve decided what that is, write it inside the circle in the center of a white board or piece of paper. Make sure that whatever you write here is a succinct, precise statement so that it’s easy to work with.

After you’ve considered and recorded what it is you want more of, think to yourself “What prevents me from getting more of what I want?” The answer to this simple question becomes the interferences that you record in the boxes surrounding your goal. Continue to list your interferences until you are satisfied that your list is complete enough to move on. There are really no rules that govern a specific number of interferences you can list, just be sure to list the major interferences as to why you can’t achieve what it is that you want more of. Make sure you include things that you might think you can’t do anything about like lunches and breaks.

Figure 1

If your ID analysis is such where time is an important factor, then it is important to quantify your interferences as a function of time. In other words, how much time does this particular interference take away from what you want? If time is a factor, and most of the time it will be, then it’s important to keep the time element constant. That is, record the time element for each individual interference using the same measure, such as minutes or hours or whatever measure you select per day or week. As you will see shortly, this will help you prioritize your interferences in terms of importance and actions. Let’s look at an example.

In this example, suppose you are working in an Aviation Maintenance, Repair and Overhaul (MRO) facility and you are responsible for increasing the number of aircraft available on a daily basis. You haven’t been meeting your contractual targets, so you’ve been receiving large $ penalty losses. Let’s assume you have already completed a process analysis using a process map or value stream map and have determined the location of your system constraint to be the wait time required to get necessary approvals to permit your maintenance work to begin on the aircraft. In this scenario you assemble a team of subject matter experts, the people maintaining, repairing and overhauling the aircraft, and you begin construction of an ID. Since your constraint has been identified as the wait time to begin work on the aircraft (or More Wrench Time), you decide that your goal should be, “Reduced wait time to begin repairs.” You ask the team the following question, “What is preventing you from beginning work on the aircraft sooner?” One-by-one you then record both the interference the team members have described as well as an “estimate” or “guesstimate” of how much time is being lost for each one.

Figure 2 is an example of the responses (i.e. interferences and estimated times) you received from the team members and the populated boxes surrounding your goal. If you just eyeball the interferences, you can see that Incorrect Assignments is the largest impediment to reducing the wait time to begin repairs at 210 minutes per week. This is followed by paperwork and waiting for the rinse crew at 120 minutes each. Once you feel confident that you have captured the predominant interferences, I recommend that you create either a Pareto Chart or a Pie Chart to prioritize the interferences.

Figure 2

Figure 3

Figure 3 is the Pie Chart of repair time minutes lost per week as a result of the interferences identified by the team of SME’s. The Pie Chart reflects the priority order to “attack” these interferences to authorize repairs to begin sooner on the aircraft.  The most important thing to realize is that of the total available time to work, because of the Interferences identified, only 42 % of the time the SME’s are actually working on the aircraft!  So by eliminating, or significantly reducing, the times associated with these interferences, there will be an immediate gain in the throughput of the process you are trying to improve and most of the time very little, if any, money is required to achieve this improvement!

Because of the length of this posting, in my next posting I’ll get back to our two other Green Belt students and how they used the Interference Diagram to help them solve their months-long problem.

Bob Sproull.

 

 

Focus and Leverage Part 173

Recently I have been working on a new account for a healthcare organization in the Chicago area.  My company, NOVACES, performed what we refer to as a JumptStart initiative which is a full-blown needs assessment.  Needless to say this assessment uncovered many, many opportunities for improvement.  Our next step was to interview the organization’s leadership team and begin the selection of the most impactful opportunities that can help them become a more successful world class organization.  I might add that this healthcare group had just undergone a significant reduction in force in an attempt to save their way to profitability.  Since this had just taken place prior to my arrival, it was clear that many of the employees were kind of frightened for their jobs.  And then here comes Bob Sproull with a message of how to do much more in terms of process throughput without adding additional labor!  You can imagine how that reception was……

One of the first orders of business was to select potential Green Belt candidates for training in what we refer to as SystemCPI^® which is an integrated Lean, Six Sigma and Constraints Management improvement methodology.    Our contract called for Green Belt and Champion training followed by at least three Value Stream Analysis (VSA) initiatives and up to three Rapid Improvement Workshops (RIW) or additional VSAs instead of RIW's.  The VSAs would be selected and scheduled after the Green Belt and Champion training was complete.  The selection process would be based upon individual interviews with the Project Champions and then presented to the leadership team for final approval.  The selection criteria would be a combination of potential financial payback and which problems were most pressing for the organization.  With the new Affordable Care Act looming, things like hospital re-admissions, patient satisfaction, infection rates, and other criteria had to be in the mix for project selection.

The first project selected was in the Radiology Department and it was a flow issue which is perfect for a VSA initiative.  In fact several of the projects selected were intended to improve the flow of the processes which is a great place for both Lean and Constraints Management.  The second project, for example, was in the Emergency Department with the objective being to reduce the “Door to Doc” time.  As these projects are initiated, I’ll try to post the progress made here in my blog.

With the Green Belt candidates selected and a significant list of improvement projects in our portfolio, we were now ready to deliver our week-long training.  The Green Belt training went off as planned for twenty-four students as they learned a variety of tools and techniques during the week.  Of particular interest was a simulation that we include in our training that involves simulated physicians, patients, pharmacy technicians, a pharmacist, nurses, etc. intended to demonstrate how a process full of waste and error prevents the distribution of needed medication to patients.  There were two teams competing against each other with the winner being declared based upon the number of patients receiving their medication.  The simulation has three rounds with the first round requiring the teams to run their operation based upon predetermined guidelines with no changes permitted.  At the end of Round 1 of this simulation, neither team had distributed a single medication to any of their patients.

The Green Belt training included a variety of tools like Process Mapping and Value Analysis to determine whether each process step was value added, non-value added or non-value added but necessary.  They also learned the true meaning of a value added activity, the seven Lean deadly wastes and various other Lean tools like SIPOC diagrams, Spaghetti Diagrams, and others.  They also learned various Six Sigma tools and techniques, but the most useful piece of the training was how Constraints Management (CM) works in this integration.  I say CM is the most useful simply because, as I’ve written about many times on this blog, it provides the focusing mechanism needed for application of Lean and Six Sigma at the right location within the process being improved.  This part of the training included a discussion of Goldratt’s Five Focusing Steps and it was very well received by all of the students.  As a side note, I’m happy to report that all twenty-four of the students passed the exam at the end of the training.

Armed with their new training, round two of the simulation progressed with the students being required to perform a Value Stream Analysis of the process used to distribute medication to patients.  In this round the students were only permitted to remove the non-value-added steps in the medication distribution process.  The teams were amazed by the number of steps that added no value and as a result of this exercise, both teams improved their results significantly over the first round of the simulation.   One team distributed meds to 24 patients and the other distributed meds to 26 patients.  Both teams were amazed with the significant improvements they had achieved by simply removing the apparent waste.

In the third round of the simulation both teams created both an Ideal State and a Future State map of the meds distribution process.  Using Constraints Management, both teams were able to identify the system constraint and focus their improvement efforts on that constraint.  I told them in this round they could use their creative juices to produce a streamlined process.  For example, one part of the process was the notification to the pharmacy of the need for meds and both teams established an on-line notification process.  Both teams established their new processes and the results even astonished me.  In this third round, I cut the Rounds 1 and 2 time from 20 minutes to only 10 minutes which both teams thought was unfair until they ran their new processes and saw their results. Team 1 led the way by distributing meds to 41 patients while Team 2 was able to distribute meds to 36 patients!  Think about that…..they had significantly exceeded the results of simulation Round 2 in only half the time!!

In my next posting I’ll discuss a couple of breakthroughs achieved by several Green Belt students just after receiving this initial training and some follow-up training on a Constraints Management case study that I gave them a couple of weeks later.

Bob Sproull

Focus and Leverage Part 172

This will probably be the final posting in this series on my Kentucky plant simply because I’ve talked enough about it.  This final episode will be about one of our other customers (the GM Corvette facility) which was situated within 2 miles from our plant.  Even though we were in close proximity, we really didn’t produce much for them and when I arrived there I wondered why.  I decided that it was time to make an unscheduled visit to see if I could get to the bottom of this.  As I drove that short distance to Corvette, I kept imagining to myself why they didn’t use us as a major supplier.  I knew we had experienced quality problems in the past, so I thought maybe that was the major reason.

When I pulled into the Corvette plant’s parking lot there was a line of these sleek vehicles parked in a line in most of the executive’s parking slots.  I got out of my car and started walking past each one, but their allure made me stop and admired each one.  I had always wanted a Corvette but could never afford to buy one.  I had never even driven one before.  As I continued stopping and looking at each one, I heard a voice behind me say, “You like these?”  I responded immediately without looking back, “You bet I do!”  He then floored me and asked, “Would you like to drive one?”  I immediately turned and looked him in the eye and smiled.  He said, “I’m serious, would you like to drive one?”  Knowing he was serious, I said, “Sure, but who are you?”  He said, “I’m the plant manager here in Bowling Green.”  I told him that I was actually coming to meet him and chat a bit about my plant’s lack of business with Corvette.  He said, “Let’s chat while we drive,” and with that he opened the driver’s side door for me and then walked around to the passenger side and crawled in.

The Corvette facility had a mile-long test track built around it so off we went.  The ride was so fast, smooth and the handling was excellent.  I was driving about 65 mph when he said, “Do you always drive this slow?”  With that I punched it and soon we were at 110 mph and it felt so good and natural.  He eventually asked me what I wanted to talk with him about, so there we were traveling at 100+ miles per hour talking shop.  I had trouble concentrating going at these speeds, but he seemed perfectly comfortable as though he had all of his business meetings like this.  I got right to the point and asked him what my plant had to do in order to do more business with his plant.  He went on to explain parts of the sorted history between the two facilities.  It seems as though even though we were the closest of all supplier plants, we were unable to ship anything on time.  And when we did, our quality wasn’t always stellar.

As I was driving and listening to him, I was thinking about what kind of an offer I would have to make to him that he simply couldn’t refuse?  “It would have to include a guaranteed on-time delivery provision,” I thought.  “It would also have to include a provision for a high enough quality level that would differentiate us from his other suppliers,” I continued.  I didn’t know it at the time, back then, but what I was considering was something we call a mafia offer these days.  He told me that he would love to do business with us again if we could show him that our facility was capable of being a reliable supplier.  With that, I invited him to come visit our plant to which he agreed.

As I drove back to my plant I had a vision of an offer that I wanted to make to him.  If he would give us exclusive business for specific fiberglass parts, I would offer him 100% on-time delivery or the order would be free.  I also decided that our quality levels we would offer would be based upon a running average that must be greater than 98% compliance to specs.  I knew we had excess capacity because of all the throughput improvements we had made, so I was confident in our ability to assure flawless delivery of parts.  And since we had a very well defined SPC initiative in place, I felt confident that we could meet the quality requirements as well.

My next thought was about the price of our products that we would offer.  I decided that we would match our competitor’s price minus 10%.  Since we had excess capacity in our fiberglass process, I knew that as long as we covered the totally variable costs which were quite low, nearly all of what we charged would flow directly to the bottom line.  I knew this because we would not be adding any additional operating expenses beyond what we already had.  The beauty of Throughput Accounting is how easy it is to make real time decisions.  Since we had set his visit for the day after tomorrow, I had plenty of time to create my mafia offer.

Right on schedule the Corvette plant manager showed up on our doorstep.  Because we had done multiple 5S events he was quite impressed with not on the cleanliness of our plant, but also with how organized it was.  He told me that the last time he was in my plant there was inventory everywhere, but since we had applied TOC to our facility, there were no longer any piles of WIP like before.  We had also done a lot of work with visual buffer management and Drum Buffer Rope concepts and techniques, so that we knew at a glance the status of all of our orders.  He was clearly impressed!  What amazed him the most was how little our raw material and finished goods inventories we had at our site.  But the one thing that impressed him the most or should I say the biggest difference to him was the obvious uptick in the morale of our workforce.

When he had seen enough of our improvements, he simply said, “Let’s go to your office and talk.”  He told me how impressed he was with all of the changes since his last visit here, but that he wasn’t sure if we could do business.  He told me that he thought it would take a while for me to generate an offer that would turn heads at Corvette.  With that, I handed him my single page mafia offer which told him that we would generate a specific SKU at 100% on time delivery, at best cost minus 10% with a greater than or equal to quality level of 98% or the entire order would be free!  He asked me if this was a real offer or simply one to make me laugh.  I assured him that it was genuine and that if he was in agreement, that my accountant could contact his accountant that day and we could deliver our first shipment within 24 hours.  He was flabbergasted to say the least and said that in all of his years he had never seen an offer like this and that he simply couldn’t refuse it!

The next day we delivered our first order and after a lengthy inspection, it was deemed 100% compliant.  A week passed by with the same results every time.  And then a month and six months with the same results each time.  In fact the only quality issues we experienced in that time period we labeling issues.  Our plant’s revenue and profitability skyrocketed as did our orders from Corvette and BMW and even the Chrysler Viper body and quarter panels were added to our mix of products.  It was an exciting time for our plant and our plant which had been scheduled to shut down when I assumed leadership of it ended up becoming the model for the entire corporation.

In my next posting I’ll be moving on to a new subject, but my memories of those days in Kentucky will remain with me forever.

Bob Sproull