Answer Just-in-time at Jimmy's

1. List the elements in St. James's new approach which could be seen as deriving from JI principles of manufacturing. At the more philosophical level of JIT, the case describes the concept of waste identification and elimination. Waste is seen as a wide range of nonadded value activities and costs. In this case students should be able to spot most of the following: excess inventor use of expensive items in lieu of low-cost ones duplicated inventor purchasing administration !too man suppliers" too man bu ers excess materials in standard pac#s cancelled appointments in $rolog surger process complexit in $rolog administration

The first six of these are t pical of wastes that can be identified in manufacturing operations, as the involve material management. The last two concern process management in administration s stems, and as the textboo# points out %some processes are themselves waste!ful"%. a" The main emphasis in the case is on elimination of waste in the purchasing s stem. &eferring to 'hapter (), on suppl chain planning and control, we see that Jimm %s relationship with suppliers is changing from a medium-term trading commitment towards a more stable long-term relationship with fewer suppliers. *ome characteristics of these relationships appear to correspond to +amming%s lean suppl concept particularl with respect to deliver practices. ,owever, it is worth discussing the conditions that ma#e this possible and the ris#s involved. In this case, the main problem appears to be the medical staff%s preferences for a wide range of different t pes of materials. To reduce input variet means standardisation, and this can be achieved b negotiation-persuasion, or b imposition-conflict. Jimm %s *upplies .anager seems to have used the former approach using cross-functional tas# forces. *uppliers must be assessed for their capabilit and interest, in order to ensure that the are li#el never to fail to deliver as promised. The ris#s, then, are around the actual dependabilit and /ualit of the suppliers. As is emphasi0ed in the case, low cost !of the purchased items" is no longer the predominant issue: long-term value for mone in the overall purchasing-inventor processes is more critical. 1ut it ma be more difficult to measure2 *o perhaps there is an element of faith !or hope" involved here.

b" Another element of improvement allied to JIT principles is the use of cellular operations. The case describes the complexit of the existing s stem for $rolog admissions, which involved 34 handovers of information. 5ne approach in class would be to as# the students what sort of information might have been involved, and which departments would have been responsible for providing it. .ost people have some idea of the main functional areas in a hospital, and so ou should be able to derive a list of around 67 pieces of information, and a variet of departments. 8ou could then as# wh the traditional large organisation, such as a hospital, divides up in this wa . Arguments for functional organisation include: economies of scale faster learning of narrow wor# content tas#s !specialisation" safet !e.g. in 9-&a and pharmac " securit of information convenient position, near inputs to the operation clear boundaries of responsibilit concentration of expertise and training.

The application of cellular principles involved ma#ing :ust four people responsible for a dedicated, self-contained admissions s stem. While the case does not give details, we can surmise that this must have involved devising a new process which cut across the functional boundaries, and gave much broader responsibilities to the emplo ees. *ome safeguards would have been made to ensure that neither the patient nor the emplo ee was exposed to the ris# of mista#es, such as the failure to notice that clinical tests had not been completed before admission. .ost problems would have been %political% since the redesigned s stem was faster and simpler. 5pposition would be expected from managers of existing functions who might have seen this as undermining their department and expertise. These problems are common in manufacturing where production cells are first established in a batch-process la out environment. c" Another example was the use of #anban s stems for some inventor management. This development was clearl in its infanc , but the case illustrates the simplicit of this approach. 8ou should remind ourself that some students who have not seen the bureaucrac of a conventional purchasing s stem might not appreciate the radical changes suggested here2 What is described is reall a two-bin s stem for consumable independent items. ;evelopments described in the case indicate that the empt carton will become the #anban communication direct with purchasing, eliminating the waste effort of the Ward *ister. It is useful to discuss the applicabilit of such s stems for other items, and compare this case with the approaches used in the Temple $niversit ,ospital boxed example in this chapter.

!. "hat further ideas from JI manufacturing do you thin# could be applied in a hospital setting such as St. James's$ There are man issues which could be discussed here. Those that have experienced outpatient treatment in a general hospital might refer to the obvious %wastes% involved with patient waiting !WI<". These can be reduced or eliminated b better scheduling. ,owever, the complexit of the product range offered b a conventional clinic and its supporting centralised functions ma#es smooth scheduling virtuall impossible, and WI< is used to buffer out the fluctuations in arrival and processing times. <erhaps the best approach here could be to separate high volume repetitive %products% and create treatment cells or plant-within-plant operations. These t pes of operation, with more focused product ranges, allow more levelled schedules and much lower WI<, often with reduced overheads and less WI< storage space !waiting rooms". If ou wish to pursue this argument with the class a good case to use is *houldice ,ospital !from the 'ase 'learing ,ouse" which describes the flow process of a focused hernia hospital in Toronto. 5ther areas of waste reduction that could be identified b students are: .otion reduction: 1etter la out can be designed into new hospitals to reduce the amount of patient and material transport re/uired !portering". In existing hospitals this ma be difficult to achieve because of old buildings and a histor of incremental, ad-hoc developments. ;efective goods reduction: Inspection-based approaches to /ualit still prevail in man hospitals. <revention-oriented /ualit should reduce /ualit costs in the long term. It is interesting to note that surger generall adheres to these principles an wa : good outcomes are achieved b attention to the /ualit conformance of inputs and processes !purchased items, training of surgeons and nurses, attention to tidiness, obsession with cleanliness and sterilit , use of standardised procedures, etc.". This approach, applied to all areas of a hospital, should bring dividends in reduction in failure costs including rewor#. The involvement of ever one: .an aspects of this !as described in this chapter" are being introduced in the more progressive hospitals. It could be argued that JIT is onl made possible b first establishing T=. principles and practices at ever level in the hospital. *ome hospitals have successfull introduced cross-functional teams for !waste reduction" problem resolution and improvement activities. In some cases, functional teams have developed service performance standards for their own wor# !e.g. porters, intensive care nursing". 5ther JIT Techni/ues: .ost of the ten techni/ues outlined in the chapter have, at first sight, little relevance to a hospital. ,owever, some ideas which might come out of a discussion, or from assessed wor#, include: Total <roductive .aintenance: A particularl important techni/ue in areas where critical pieces of expensive machiner are involved !e.g. scanners, 9-&a , intensive care". Improved up-time not onl improves

clinical safet , but also reduces the costs of rescheduling and lost utilisation. *et-up reduction: This approach could be important for activities such as bed linen changing, operating theatre set-ups, and clinic changeovers. >isibilit : Increasingl seen around wards, clinics, etc., to show utilisation, waiting times, problem anal sis, etc. ?anbans: 'ould !perhaps" be applied to moving of patients as well as materials2