• Lean is the "one true path"
• Lean is easy to implement
• Goal is zero inventory
• No "tradeoffs"
• Make things only when the customer wants it

1. Stabilize schedule
2. Improve product design
3. Reduce inventory
4. Work with vendors
5. Improve quality control
6. Improve design flow process
7. Establish kanban system

• Level Schedule
• Underutilize capacity
• Establish freeze windows

• Standardize product configuration
• Standardize/reduce # of parts
• Process design with product design
• Design for manufacturibility

• Fewer suppliers
• Relationships are long term based on cooperation
• Suppliers must strive to continuously improve

• Jidoka - fix problem right when it occurs
• Enforce compliance: quality first, output second
• Housekeeping: sort, straighten, sweep, standardize, self-discipline
• Kaizen
• Automatic inspection/100% inspection
• Misktake-proof the process

• Link operations
• Balance resource capacities
• Re-layout for flow
• Emphasize preventive maintenance
• Reduce lot sizes
• Reduce setup/changeover time

• "Info-based" flow
• Minimal setups
• Well characterized/understood process
• Kaizen

• Consider product rather than process layouts -use "cellular production" or the use of semi-autonomous teams working on different tasks for the same goal
• Use task overlapping to create within-cell pooling
• Reduce batch sizes
• Mistake-proof the process
• Design jobs for multi-skilled employees

An item is realseased for production at a specified time with an associated due date (controls throughput > WIP)

Explicitly limits the amount of work in the process (aka inventory/unfinished products) that can be in the system ( controls WIP > throughput)

A system in which one station of work cannot start production without its succeeding station specifically requiring for production (a chain reaction)

• Prevents buildup of inventory
• Maintains discipline of pull production
• Allows kanban to authorize movement of goods

• Control - a process is said to be in control if there are no special causes for variation and other there are only common causes for variation
• Capale - a process is capable if it is within the specified design limit

A system in control may have a lot of variation and only management has the power to reduce defects because only management has the power to change the process

• Define - define root causes
• Measure - measure baseline metrics
• Analyze - identify root causes
• Improve - determine optimal solution
• Control - sustain gains with reporting

• Defines strategic goals
• Promotes six sigma
• Establishes business targets

• Requestor of project
• Defines project goals, objectives, and scope
• Removes barriers and aligns resources
• Key communicator of project progress

• Responsible for sustaining long-term gains

• Full time project leaders who are expert in Black Belt methodology

• Experts in their field of work that is related to the project

• Participate in local communication
• Problem analysis
• Improvement of design and implementation

• Huge investment
• A cultural change
• Just a bunch of already used quality techniques repackaged into one system
• Rewards systems and has measures that do not distinguish between "quality" and "luck"
• Identifies random variation as "problems" and then tries to find a solution to these "problems"

1. Create a safer environment by reducing medical errors
2. Become a "best place to care" reduced turnover
3. Become a preferred place to care, gain market shares
4. Reduce variability and process waste

The theoretical flow time of the longest path in a process flow chart

Used so management knows which activities on the path are "critical" or most variable and thus need most focus

Reduce the work content of activities on the critical path

• Eliminate non-value adding subactivities (work smarter)
• Increase the speed
• Reduce number of repeat activities
• Change patient mixup
• Design for efficiency 

Move some of the work content off the critical path

Minimum capacity of any step or key resource for the process (aka the capacity of the bottleneck)

Capacity = (1/unit load) x batch size x availibility x number of resources

• Focus on the bottleneck
• Increase capacity of the bottleneck (1. decrease work content at bottleneck; 2. reduce necessary batch sizes; 3. increase # of bottleneck resources; 4. increase schedule availibility)
• Increase the net availibility by managing resource downtime and setup times
• Decrease resource idleness
• Manage supply and demand to limit strain on the bottleneck

The number of units that flow through a specific point of the process per unit time

Governed by demand

Long Run -

average inflow rate = average outflow rate

Fraction of time resource is busy

Throughput rate/capacity

or

Input rate (units/hour)/possible output rate (units/hour)

Stable system - utilization rate < or = 1

"Product" Layout

Time -

Quality -

Inventory -

Scheduling -

Flexibility -

Demand changes -

Product mix -

New products -

• "Patient focused" care
• Service line production
• However, lack of pooling makes large variation aka difficult

Time -Shorter lead times

Quality -Faster feedback

Inventory -Lower WIP

Scheduling -Well defined

Flexibility -Less flexible

Demand changes -Less easy to absorb

Product mix - Limited and fixed

New products - More difficult to introduce

"Process" Layout

Time -

Quality -

Inventory -

Scheduling -

Flexibility -

Demand changes -

Product mix -

New products -

• Departmentalized - all personnel of one type are grouped together

Time - longer lead time

Quality -slower feedback

Inventory -High WIP

Scheduling -Difficult

Flexibility - More flexible

Demand changes -Relatively easy to absorb

Product mix - can be large and variable

New products -can incoroporate new products easily

The adding together of multiple sources of variability that makes the whole less variable (effectively)

Example - tossing a coin 5 times in comparison to 50

• Reduced points of coordination between team members
• Increased teamwork
• Increased expertise in treating specific diagnosis
• Shorter response times

• Integrality
• Loss of flexibility

• Ti = average time between arrivals
• Tp = average processing time of a job
• c = number of parallel servers
• Arrival rate (measures throughput rate)= 1/Ti
• Service rate (measures capacity) = c/Tp
• Ri < Rp - adequate capacity
• Utilization rate = Tp/(c x Ti)

Inventory = Throughput x Flow Time

Flow time - time it takes for a unit to go through the system

Throughput - the rate of arrivals

Q x A = E

Q - quality of solution

A - acceptance of major stakeholders

E - effectiveness of process

• Labor costs - 10%
• Manufacturing costs - 40%
• Production not near customers
• High degree of automation
• Variation is reduced

• Labor costs - 65 to 75%
• Material costs < 15%
• Production always in close proximity to customer
• Industry wide shortage of critical skills
• Limited automation to replace labor
• Must accept variation as much of it cannot be removed

• Position initial projects to be based around patient care quality and not cost
• Pick the right sponsor and team
• Start out with a low budget project and show results to major stakeholders
• Always manage scope and expectations
• Involve key stakeholders from the beginning

• Diagnose patients for acute and chronic conditions
• Order and perform diagnostic tests
• Order prescriptions
• Counsel patients
• Manage patients overall care

• Have a Bachelor of Science in Nursing degree
• Be a registered nurse for 1 year
• Go to nursing school for anesthesia (24 to 36 months)
• Pass certification exam after graduation

In order to provide care in a timely fashion, hospitals set up a threshold time T, and any patients waiting after T is unacceptable (needy patients get priority)

Physician groups in hospitals should decide what T is

Realize that compliance cannot be fully governed

Some hospitals turn away patients in order to keep their T level up

• Relatively straightforward and generally easier to understand
• It can answer "what-if" types of questions without actually changing or building a real system
• Generally safer and cheaper to experiment than a real system

• Expensive and time consuming to develop
• Does not give optimal or exact solutions to the problem

• Multifunctional in scope, tracking a range of activities from financial results, procurement, sales, operations
• Integrated in nature
• Modular in structure

• 30,000 companies worldwide
• Costs a fortune for companies (billions of dollars for large companies)
• Takes many years to complete: 1 to 4 years

• Senior management was thoroughly involved
• Cross functional implementation team
• Teams spent great detail in how implementation was going to be carried out
• Clear guidelines were laid out on performance measurement
• Established clear guidelines on how to use outside consultants
• Developed detailed plans for training users

• Financial
• Human resources
• Resource utilization
• Materials management
• Facilities and project management
• Office automation

• Employee information
• Position control
• Labor analysis reports
• Inventory of skills
• Information for labor cost allocation
• Productivity information
• Compare compensation with competitors

• Patient scheduling
• Clinic use
• Emergency department use
• Ambulatory surgery centers

• Connect with clinical decision making systems to flag procedures that precede or require other procedures
• Connect with inventory systems to automatically order needed supplies for scheduled procedure
• Connect with HR to assess personnel need, allocate personnel
• Connect with patient database to remind patient to show up

• Requisitions for suppliers checked against budget
• Electronic data interchage with suppliers
• Bar codes, RFID chips
• Food services management

• Maintenance of buildings
• Manage new projects or renovations

• Simplify and standardize IT systems
• Have access to accurate information for better interaction and communication with patients, health professionals, and suppliers
• Improve the availibility and quality of data
• Will result in lower inventory, shorter delivery cycles etc
• May contain decision support capabilities

• Loose coupling of services with operating systems
• Allows different applications to exchange data with one another.
• Systems package functionality as interoperable services

• Provide data about diagnostic and treament events retrievable electronically.
• Real time data entry and retrieval
• Link scheduling, billing, referrals
• Data can be interchanged with other agencies
• Allow real time access by providers/patients for information

• Passive - present information culled from other systems about patient and medical science
• Active - patient specific information from clinical databasem and rule-based inference engine; combines them to generate specific suggestions

• Transponder which receives radio signals and in response sends out a radio signal
• Antennae, small chip, and stores small amount of data
• Programmed at manufacture or installation
• Powered by the electromagnetic field generated by antennas

• Unique identifier
• Read many at once
• No line of sight required
• Easy to conceal
• Works well in harsh environment

• Can be very sensitive and calibrating the antennae can be tricky
• Can be expensive
• Don't get instand feedback of a bad scan (sometimes no way to tell)

• Inserted into catheters to notify when it has been in use for 72 hours
• Prescription disbursement and dosage
• System logons
• Key asset tracking

• Iterative - compromised of multiple cycles
• Recursive - each step based on the outcomes of the former
• Customized
• Uncertain

• Problems are well known
• Unitary - only one problem (one disease etc)
• Known solutions (linear - protocol exercised without variation; standardized; certain - solution works)

• Rapit throughput rate
• Minimal queue time
• Low cost
• One stop shopping
• Let the customer do the initial triage

• Cannot treat all diseases (what do they do if a patient comes in and needs immediate treatment?)
• More volume, more risk
• Little price elasticity
• NP's becoming bored
• Patient flow is unpredictable
• Management team not proven for growth
• Criticisms by physician groups over quality of care
• Uninsured patients expected PCP type service and consuming service time
• No significant barriers to entry