I want to begin this session with a quote from Dr. Sandeep Jauhar, from his book, Doctored. We did stress tests on at least three-quarters of the patients who came in. There is almost no evidence to recommend stress testing in patients with recent coronary stenting. But their staff did these routinely. There is no evidence that stress testing for coronary artery in intermediate risk adults without symptoms is beneficial. But this was the bulk of the practice. The more tests you perform in a lower risk population, the more falsely abnormal results you're going to get. Leading to further testing, and potentially harmful, invasive studies, like cardiac catherisation. As this quote emphasises, modern healthcare, particularly in the U.S., does many things that are not a value to patients. Many of these tests we order, do not improve their health and wellbeing, and may even cause harm, as described by Dr. Jahar. As a consequence of overtesting and overprescribing, US healthcare now costs 3 trillion dollars per year, consumes 18 percent of the gross domestic product. This is twice what any other country spends. The annual cost is now increased to $10,000 per person in the United States. Experts estimate that 30% of what we do is waste. Some suggest 60% of all we do is not of value. US is the worst offender. But no matter where you work in health care, waste is a huge problem. We can all learn from the US what not to do. By embracing a systematic approach to waste reduction we can all become experts on how to improve the value of health care in our country. Why should we all strive to reduce waste? Production capacity equals work minus waste. To improve productivity without increasing the workforce, a workforce being a high fixed cost that also increases complexity, we need to remove waste. Improved efficiency reduces cost, and reductions in cost improve value. Remember, value equals quality divided by cost. An added dividend of using TPS or LEAN, is that experience has shown that quality will also improve further, and further increase value. Why do we ignore waste? Tradition. This is the way we do things. We would have to admit that a good portion of our job is likely to be wasteful. And probably most important, we don't recognize waste. We simply don't see it. I recommend that everyone in healthcare continually ask the question. Is this a value to my patient? Waste is anything that does not add value from the perspective of the customer. The Japanese call this Muda, nonvalue added activities. Toyota Production System recognized the importance of removing waste over 60 years ago. In order to recognize and reduce waste, they have categorized the forms of waste. As we discussed in the first week, waste reduction is the very foundation of Virginia Mason House, as well as for Denver Health. There are two major categories of waste, particularly in health care, listed on the left of this slide. Type 1, non-value added, but were required because of regulations. This is the category of waste requires legislation and negotiations to remove. Type 2, non-value added, that can be stopped immediately without detriment. This is the form of waste we should primarily be focusing on. Now let me introduce you to the TPS Waste Wheel that describes seven forms of waste. First, motion, most hospitals are not designed with the idea of minimizing motion. Of the nurses, physicians, and other health care workers. As a consequence this is a major form of waste in healthcare. Let me share an example documented below of this in the lower part of this slide. As the senior physician, supervising residents on a multi-disciplinary team, I have experienced a need for increased unnecessary motion. Over the past four years, our hospital occupancy has progressively reached 90 to 95%. As a consequence, rather than being assigned to a single ward, our patients end up being located on seven different floors. And I have noticed that the number of steps and distance I have traveled each day to see my patients has doubled. From 3,200 steps, or 1.5 miles, to 6,400 steps, or over three miles. If I walk quickly at three miles per hour, that means on any one day, I waste one hour per day walking from room to room. Standard work and value stream mapping are tools that can dramatically reduce this form of waste. Two, defects, probably one of the most serious defects in medicine is misdiagnosis. As prescribed in fixing health care 1.0, my former wife Mary's illness was misdiagnosed. And as a consequence, the cost for care increased by sixfold. Delays in care and errors are costly both when it comes to money, and when it comes to human suffering. But, more about these issues later. TPS has a systematic approach for preventing defects from ever reaching the customer. In our case, the patient. The next form of waste is transportation. Diagnostic testing sites are often located significant distances from the clinics and in-patient beds, requiring patients to travel long distances. Hospital and clinic warehouses are often offsite requiring continual transport of goods These arrangements waste fuel and human resources that could be devoted to direct patient care. The next form of waste is inventory. Nearly every hospital ward and in every clinic, there is clutter and excess inventory. Below is a picture of our ward showing two unused wheelchairs and a bedside chair in the hallway. The objects create obstruction, waste space, and create a potential fire hazard. And now the problem is the storage of outdated equipment and forms. We will discuss inventory in more detail when we discuss 5S. Another major form of waste Overproduction, a quote from the book Doctored, focuses on this widespread form of waste, particularly in the United States. When there is excess capacity, for example, a new cardiac catheterization laboratory, this creates artificial demand because health systems need to pay for this new equipment. They need to achieve return on their investment or ROI. Time, what can you never get back? This is one of the most notorious wastes in health care. Requiring patients to wait disrespects patients, and delays in care can result in patient harm. Value stream mapping is a very effective method for removing this form of waste. Overprocessing, the inclusion of an excess number of steps, such as creating additional unnecessary inspection steps, and requiring approval signatures that are unnecessary. Requiring paper copies when the computer is sufficient, remains a common form of waste in health care. We will be learning how to use process flow mapping. Shown at the bottom of this slide, to reduce this form of waste. Finally, I would like to add one form of waste common in health care. Wasting human potential. Always design work that maximizes each individuals education and training. Too often physicians and nurses are required to perform mundane tasks that require little training. Given the hourly cost of these highly trained individuals this wastes money and distracts them from performing the more sophisticated work. Required to assure high quality patient care. Now that you understand all the forms of waste in our subsequent classes, I'll be introducing you to four sets of tools designed to eliminate waste. First, 5S. Second, standard work and setup reduction. Third, value stream and process flow mapping. And fourth, product quantity analysis and production leveling. Using these tools, each of us can reduce waste by 30 to 60%, allowing more of our healthcare budget to be voted to improving the health and well being of our patients. Reducing waste decreases complexity, thereby increasing the reliability of patient care. Waste reduction has also been shown to increase patient satisfaction and staff satisfaction. And finally, improving job satisfaction reduces burnout, a serious problem in modern healthcare. Thank you.
