LEAN PRINCIPLES

Abstract

Lean thinking begins with driving out waste so that all work adds value and serves the customer's
needs. Identifying value-added and non-value-added steps in every process is the beginning of the
journey toward lean operations.

How lean can (Institute

apply
to healthcare
for Healthcare
Improvement, 2005)

Acknowledgements
Hanna Close
Jordan Beatty
Andriana Vanezi
Victoria MacDonald
Raymond Dolch
Benafsha Hssanzada
Xiomy Brenes
Kristen Jantzi
Alexandra Hernandez
Ilkay Sakir

Contents
Introduction................................................................................................................ 3
5 Core Principles of Lean............................................................................................ 4
Identify Value.......................................................................................................... 4
What does the customer want?............................................................................4
Map the Value Stream............................................................................................. 4
How Mapping the Value Stream Applies to the ED...............................................4
Create Flow............................................................................................................. 5
How to Create Flow in the ED...............................................................................5
Establish Pull........................................................................................................... 5
Establishing Pull in the ED.................................................................................... 5
Seek Perfection....................................................................................................... 5
Seeking Perfection in the ED................................................................................ 6
Lean Improvement Tools............................................................................................. 6
Lean Improvement Tools Defined............................................................................ 6
Takt Time.............................................................................................................. 6
Direct Time Observation Diagram........................................................................6
Loading Diagram.................................................................................................. 7
Spaghetti Mapping............................................................................................... 8
Circle diagrams....................................................................................................... 9
Flow Diagram with Value Added and Non-Value Added........................................9
Standard Work.................................................................................................... 10
Putting Lean Tools Together...................................................................................... 11
A3 Thinking........................................................................................................... 11
Value Stream Mapping and Analysis......................................................................12
Kaizen.................................................................................................................... 12
5s.......................................................................................................................... 13
Value Added vs. Non-Value Added............................................................................ 13
Value-Added.......................................................................................................... 13
Non-Value Added................................................................................................... 13
7 Wastes of Lean...................................................................................................... 14

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Transporting.......................................................................................................... 14
Inventory............................................................................................................... 15
Motion................................................................................................................... 15
Waiting.................................................................................................................. 15
Overproduction..................................................................................................... 15
Over Processing..................................................................................................... 15
Defects.................................................................................................................. 16
Works Cited.............................................................................................................. 16

Introduction
This document will allow readers to learn everything there is to know about how to
be efficient in all aspects of lean. By reading this simple manual, the readers will

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learn important information about lean such as: principles, tools, what the
differences between value added and non value added is, and it also describes the
7 wastes of lean.

5 Core Principles of Lean

Identify Value
This principle is about identify the value, this is determined by the customer
(Mahalik, 2016). The customer wants to buy the right product, at the right price and
with the right capabilities. It is the customers needs for the product (Crawford,
2016). This can typically be broken down into three main topics. The first is quality,
this is whether the product has all of the functions and delivers everything the
customer wanted (Lean Manufacturing Tools, 2016). The second is cost, this means
providing the customer with the product as economically as possible Lean
Manufacturing Tools, 2016). Lastly, there is delivery, this is ensuring that you
complete the product on time (Lean Manufacturing Tools, 2016). Some of the tools
used to identify value are Quality Function Deployment and Value Stream Mapping
(Lean Manufacturing Tools, 2016). These tools will be discussed later on in the
manual.

What does the customer want?

When patients enter the emergency department their main goal is to receive
medical attention as quickly as possible and either be discharged or admitted as
soon as possible. Quality care in a timely manner is highly valued to all patients.
Quality is referring to thorough initial assessments, ongoing communication with
clinicians and patients as well as patient information on how to manage their illness
after discharge. To achieve care in a timely manner it is essential for the triage
process to be completed as quickly as possible. In addition, it should be the goal of
the clinician to treat each patient so further visits to the ED for the same condition
are not required.

Map the Value Stream

This principle involves mapping out all of the steps that are required taking the raw
materials and producing the final product that the customer requested (Crawford,
2016). This requires drawing, on one page, all of the steps that the materials will go
through to reach the final product (Crawford, 2016). Drawing out the process allows
you to identify the steps that do not add value, and you can determine how to
remove these steps from the process (Crawford, 2016). This exercise should result
in a better understanding of the process that the product goes through (Crawford,
2016).

How Mapping the Value Stream Applies to the ED

The next principle can be applied to the ED/hospital by analyzing the current state,
as well as future designs. The following factors can be looked at: length of stay,
time it takes to get lab results, time from triage to medical assessment, and
punctuality of surgery times. If hospitals are aware of these, then they can set goals
to strive towards. This principle only includes steps that can add value to the goal
such as; user stories and process modeling. Its important to look at this from the
point of view of the product. For example, patients are the customer, hospitals are
the supplier, hospital staff are the workers, and treatment is the product. By looking
at how all these tie together, it shows how important this principle is to contributing
to having a more lean organization.

Create Flow
The focus of this principle is rapid product flow (RPF); to move the item or person as
quick as possible without affecting quality or customer satisfaction in a negative
way (Mahalik, 2016). The lean expert(s) examines the process flow whether human,
machine or both, and records the distance the product or employee travels from
one step to the next. The non-value-added distances at each step of the process
flow are eliminated by changing the layout of the workplace (Eba, 2016). When
successfully implemented productivity can increase by more than 40% (Mahalik,
2016). With the productivity increase, more tasks can be completed with less
resources needed.

How to Create Flow in the ED

This principle can be applied to the ED/hospital by creating flow of the product/value
from one step to the next. Each step in this process is a value adding step. Consider
the following scenario; you begin with an initial assessment, or in other words, you
are ordering the product. The next step in assigning a CTAS score. This prioritizes
the consumer based on observation and it also determines the speed of delivery.
Next is the medical assessment, where communication with the consumer happens
in order to determine what kind of care they require, and it also looks at product
requirements. Then comes lab work and imaging, this ensures that the
requirements are correct for treatment, and it tests the product requirements. The
next step is diagnosis, where the hospital staff select the most appropriate model
for treatment and the product is finalized. Now is the treatment step, which is where
the patient receives personalized treatment (product), and it is delivered to the
consumer (which is the patient in this case). Finally, is the discharge plan, which
prevents recurring orders of the same product, and provides education on the
product (not coming back to the ED for the same disease).

Establish Pull
Pull ensures there is little or no overproduction happening throughout the process
flow (Mahalik, 2016). Creating more than what is needed is wasteful in both time

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and products. Products should only be made if they are ordered and will be
delivered right after production (Mahalik, 2016). They should not be laying around
waiting to be used/sold. The focus of this step is making to customer order to
eliminate wastefully producing work (Eba, 2016).

Establishing Pull in the ED

The next principle is establishing pull, and this is manufacturing the product only
when it is ordered, and there is no inventory. This connects to the ED/hospital by
complete utilization of staff, and look at a staff/time/work ratio. This means having
certain staff working based on predicted consumers. An example for this is to make
sure that enough beds are available for predicted consumers, and not to put out
extra beds when predicted consumers are low.

Seek Perfection
The focus of this principle is continuous improvement. Once you improve the
process, you then go through the Lean Manufacturing Principles over again to
improve the present state (Eba, 2016). The improvements never end and the
organization should always be aiming to achieve the perfect state; delivering
what the customers want, when they want it, with no wasteful production (Mahalik,
2016). It is very important to remember that there is always room for improvement.

Seeking Perfection in the ED

The next principle is seeking perfect, and this connects to the ED/hospital by
delivering what the customer wants, when they want it, and at a minimum price
with zero waste. By giving patients the treatment they needs when they need it, at
an affordable rate, as well as without making the patient wait and using
unnecessary hospital resources.

Lean Improvement Tools

Lean Improvement Tools Defined
Takt Time
Takt time is the lead calculation (first step) in Lean improvement and drives many
other aspects of the system. The word takt is derived from the German word
taktzeit meaning rhythm or beat. The takt time acts as the heartbeat of the process
(Brecaw, 2012). To calculate takt time a mathematical formula is used to reveal the
output of goods and services. Staffing calculations, process monitoring, supply
chain management and space derive from this calculation (Brecaw, 2012).
Takt time = Time available to work / volume of work to be completed
Example: Emergency Department

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Available time: 24 hours
Volume of work: 100 patients
Takt Time(Tt): 1440 minutes / 95 patients = 15.1 minutes, round to 15

15 mins is the rhythm of the process not the amount of time a patient stays-new patient must enter every 15 mins and a patient must leave every 15
minutes (discharged or admitted to another department)

Direct Time Observation Diagram

The purpose of the Direct Time Observation Diagram is to identify the 7 wastes in
the form of motion(people), transportation(goods), over processing, overproduction,
waiting, defects, and inventory in a process it is best to go where the work is
done(gemba) (Brecaw, 2012). It is important the staff members being observed are
always put at ease by explaining the purpose of observations which are to eliminate
waste not staff as people are uncomfortable when a team shows up with stop
watches and clipboards. Observing the Lead time is important, (Lead timetotal
time between customer need and customer need met. Wastes should be
removed from the customers point of view (Brecaw, 2012).
Steps:
1. Units of time are added to direct observations
2. Observe at least 10 cycles of work to determine the steps in the process
3. Use two people one with the stop watch and the other recording) and long
processes observation can be done with video camera
4. The two lowest numbers that repeat are recorded in the task time column
Example: processes of a patient visit sums to 60 mins but total lead time is 105
mins, indicating the patient is waiting for 45 mins, but would not be realized by only
observing process

Retrieved from:
http://www.qualitydigest.com/IQedit/Images/Articles_and_Columns/2013/Sept_2013/TOF1.jpg

Loading Diagram
The loading diagram is also known as cycle time/takt time bar chart. The diagram
demonstrates the relationship between takt time and cycle time. It is used to
determine the number of staff needed to run within takt time (Brecaw, 2012).

Minimum staffing = cycle times(Ct) / takt time (Tt)

Steps:
1. Calculate takt time
2. Draw a red dashed line from the Y axis to represent takt time
3. Indicate each person with their own bar and each task they perform with a
different colour along the X axis
4. Add the cycle times of each person and divide by takt time
5. Calculate staffing load
6. Perform analysis for improvement (cycles under takt or over takt time)
7. Re-balance the activities of staff, move segments of work to have an even
distribution of time
8. Re-formulate the loading diagram after standardizing work and balancing

Considerations:
Healthcare has legitimate barriers to balancing as some work cant be shifted. For
example, only physicians can do their work. There is contention surrounding nurses
pottering patients or changing beds to balance work. To account for vacations and

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time off by dividing the minimum staffing by 0.85 depending on vacation policies
and access to part time staff (4 / 0.85 = 4.7 round to 5)(Brecaw, 2012).
Example: See Diagram below

Minimum staffing = Ct (5+1.8+4.57+2.5+0.75) / Tt 3.5

= 14.62 / 3.5 = 4.18 round to 4
Loading diagram indicated overstaff (5 staff when 4.2 are only needed)

Retrieved from:
http://breakthroughhorizons.blogspot.ca/2010/06/loading-diagram.html

Spaghetti Mapping
Spaghetti Mapping illustrates waste of the motion or transportation so it can be
eliminated. Motion and transportation consume time, space and resources but do
not add value (Breaw, 2012).
Steps:
1. Diagrams are first made with pencil and paper
2. A line is drawn from starting point to destination every time steps are taken
(motion) or goods are transported
3. Steps are then converted to distance using scale or measurement wheel
4. Can be transferred to computer for easier analysis

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5. Aim to reduce steps or transportation by 50%

Retrieved from: https://www.google.ca/url?

sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjltqj_ytXPAhUG64MKHVqtBgEQjRwIBw
&url=http%3A%2F%2Fwww.createasoft.com%2FIndustries%2FHealthcare-Simulation%2FEmergencyDepartment-Simulation&psig=AFQjCNHoTkndFuG5lhjFZs9iT-J7_rDzOg&ust=1476372644759406

Circle diagrams
Circle Diagrams are used when
movement is less obvious. They are
perfect for tracking the flow of
information ie. Faxes, e-mails,
computer programs. To use create a
circle diagram a line is drawn across
the circle every tine there is a hand off.
Hands offs increase errors with verbal
flow of information which occur in
health care settings especially ED.
Consider the game Telephone, where
the message becomes distorted
through handoff. Aim to cut out unnecessary hand off to reduce waste (50%
reduction in handoffs) (Brecaw, 2012).

Retrieved from:
http://www.slideshare.net/Vijay_Bijaj/thedacareimprovement-system

Flow Diagram with Value Added and Non-Value Added

To fully understand process, the workflow must be analyzed. Analysis of process
identifies tasks performed, starts and stops, waiting, connections, and handoffs
(Brecaw, 2012).
Steps:
1. Use sticky notes to define steps and post on wall

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2. Clearly define the beginning and end of the process, all discussion must stay
within the scope boundaries
3. Create process map from the standpoint of the customer (ED patient intake
to discharge)
4. Best for workers to map to gain as is situations rather than should be as
management tends to do
5. On each step of the process (each sticky) label either value added (green
dot) or non-value added (red dot) Remember: Non-value added is in terms
of the customer not the staff or organization
6. Non-value added steps are now apparent and the process rework to
eliminate waste can begin

Retrieved from: http://www.systemico.ca/value-stream-mapping/

Standard Work
Standard work is the recipe for the easiest, safest and best method to perform tasks
to create a consistent outcome. Standard work is based on the process analysis
and the tested solutions (Brecaw, 2012).
Developing standard work provides: Best, easiest way to do a job, a way to
preserve expertise, a measurement for performance, show the relationship of cause
and effect, a basis for maintenance and improvement, provide objectives and
training goals, prevent errors, and minimize variables (Brecaw, 2012). Lean
standard work can be defined by documenting the takt time, work sequence and
SWIP. Standard work tool allows for audit to ensure standard work is being followed.
If tasks are not completed in takt time or outcomes vary it is evident standard work
is not being followed or waste is creeping back in (Brecaw, 2012).
A Lean standard is based on takt time, work sequence, and standard work in
progress:

Takt Time--Standard work must be capable to meet takt time (standard

work that is consistent but fails to meet customer need is wasteful)

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Work Sequenceset of tasks completed in the same order in the
same time increments to ensure consistent outcome. Do not under
estimate staffs emotional investment in their current work sequence,
each person has their own way of working. Change Management is
iatrical to successful process change: consider getting all physicians
to agree on a standard order set or convincing a 30-year veteran
nurse to change processes. Continuous improvement is necessary
where staff will be testing the standardized work for best and offering
suggestions (Brecaw, 2012).
Standard Work in Process (SWIP)SWIP is a calculated number that
indicates how many items need to be in progress to maintain takt time
(Brecaw, 2012).
o SWIP = Ct cycle time / takt time (Tt)
o

Example: Emergency Department

Takt time = 15 minutes (patients arrive 4 per hour (60min / 15 min))

Cycle time for tasks (triage, registration, assessment, discharge) can
be balanced within the takt time
Patient needs lab work and the lab work cycle time equals 45 mins
In order for continuous flow with take time SWIP must be calculated
SWIP = Ct of lab work 45 mins / Tt 15mins = 3
Therefore 3 patients must be work in progress to maintain takt time

Retrieved from: http://www.systems2win.com/solutions/SMED.htm

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Putting Lean Tools Together

A3 Thinking
The process and thinking for problem solving based on the scientific method;
frequently used to document problem solving exercises, status report, and
business cases; named for the size of report paper.

A3 Thinking serves several purposes but the key uses are:

Problem solving and/or improvement

Communication of problem solving and/or improvement activities

Approval of resources or justification of use

Committee

Documentation of strategy

Lean improvement identified from a value stream map

Lean organizations use A3 thinking to guide the problem solving efforts of most of
their team based improvements. It is a great tool to integrate the application of
tools so that waste can be seen and eliminated.
A3 Tool:

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Value Stream Mapping and Analysis

Tool used to reveal waste in a value stream and develop a plan for
improvement. VSM provides a structure and process that identify waste
within a value stream, identify the source of the waste, and develop a vision
for the future and an action plan to deliver the future process. A value
stream consists of all the process activities require to deliver value to a
customer. Beginning with the customer definition of value, the value stream
covers all the tasks done to deliver value.

Kaizen
The process used for continuous improvement to eliminate waste and create
more value.

A kaizen is a team based approach to rapid cycle improvement. Spanning 2-5

days depending on the scope of the activity, the scientific method is followed
to deliver an improved process in a portion of value stream ending with
standard work, visual management and process control.

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5s
Five steps whose names begin with S that are used to develop a high
preforming work area.

Seiri (Sort): Removing unneeded or unwanted items from the workplace.

Seiton (Straighten): The neat arrangement of remaining items.

Seiso (Shine): Through cleaning of the workplace to return it to like-new

conditions.

Seiketsu (Standardize): The creation of standard conditions to keep the

work place standardize and organized by creating practices that enable
standard work and proper work flow.

Shitsuke (Sustain): The personal discipline required to achieve the first

four steps.

Value Added vs. Non-Value Added

Value-Added
Only an activity that physically changes the shape or character of a product of
assembly can add value. There are a few ways this can be done by various
principles. The first principle is to identify value as perceived by customers. What
does customer really want? What are they willing to pay for? This can be broken
down into three quality areas. The first one is quality. Does it function or look as
described, and does the product or service have all of the function and deliver
everything that you wanted. Another aspect is does it have everything that the
customer expects and needs. The next area is delivery. Are the customers getting it
when they want it? Many companies make customers wait when they want it now.

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Being able to reduce your lead times can be good for many companies. Ultimately,
value IS giving customers what they want when they want it. The last area is cost.
Customers dont want to be paying more then they need to for anything. It should
be done in the most economical way possible without creating waste.

Non-Value Added
Lean principle is all about reducing waste and waste is everything that is not adding
value in the eyes of the customers or patients. In other words, the idea is to
maximize customer value while minimizing waste. The goal is to provide perfect
value to the customer through a perfect process that has zero waste. But what does
it mean by process and waste? Process is a collection of interrelated work tasks.
This means everything we do in life for example driving to work, it can be broken
down into tasks that is initiated in response to the event that achieves a specific
result for customer of the process. The process has three versions. The first version
is, what you think it is, second is what it actually is and finally what it can be. In
order to identify what the non-value added is, lean has to focus on what it could
be and see if the value is added to patient or if it is non value added i.e. waste.
Non-value added pertains to aspects of the process that do not improve or enhance
the patients satisfaction. For example:

Long registration times

Long wait times
Errors in patient history
Errors in medication history

These will reduce patient satisfaction and not add value to their overall ER
care and in most cases it will add to the costs of healthcare (for example, in
Canada the government would have to pay for the above unnecessary)

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7 Wastes of Lean
When talking about the 7 wastes of lean you may come across the acronym
TIMWOOD. This acronym is widely recognized and a simple way to remember the
seven wastes (Lean Manufacturing Tools, 2016).

Transporting
The waste of transportation happens when materials or patients are moved around
the healthcare environment inefficiently. The transport waste adds no value to the
product. The hospital pays staff to move materials or patients to their designated
area, but this process only cost the hospital money. In healthcare some examples of
transportation waste are when patients and materials are moved between work
centers, departments or room to room. Some more examples include transferring
supplies from the storage area to the floor, moving information through email or
EMR, and transferring meals from the kitchen to the floor. However, some of this
transportation is needed waste but can still be reduced, even if it cannot be entirely
eradicated. The waste of transportation comes at a high cost to the healthcare
industry and attempts to reduce it must be made.

Inventory
Healthcare tires to reduce inventory waste related to storage, movement, spoilage
and wastage. Some examples in healthcare are medication that may become
expire, damaged or obsolete. Inventory feeds and can hide many other wastes that
increases the costs throughout the entire system. Examples include producing preprinted forms, drawing and keeping blood samples, and excess bedside equipment.
Inventory has other costs such as the space it takes to package and store products
and the transportation of it.

Motion
Motion waste within healthcare signifies the unnecessary movement of patients
throughout the work center. This type of waste is the least costly compared to the
other seven wastes. Each motion made in the hospital is a form of waste and causes
stress to the employees and equipment. Examples of motion throughout the
hospital include nurses walking from the nursing station to the medicine room to the
patient room. This waste also includes navigating through the EMR as well as
searching and gathering for materials and equipment. One example of how we can
work towards eliminating motion waste is to reduce the number of clicks in a
software system.

Waiting
Waiting occurs when parts of the system cannot flow together or when team
members cannot perform their responsibilities due to problems. These problems
include a lack of inventory or when the equipment fails. Waiting in healthcare

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proposes a problem for both the patients and providers. Examples of waiting in
healthcare include patients waiting in exam rooms, staff members with unequally
distributed workloads. Other examples include ED patients waiting to be admitted
or discharged from the hospital and waiting for their test results or other
information.

Overproduction
Overproduction is one of the seven wastes that can easily be diminished with proper
flow and communication. This waste occurs when hospitals have more products
than necessary and produce products that are unnecessary or not required for a
while. Poor communication between suppliers and their customers is one of the
leading causes of overproduction (Lean Manufacturing Tools, 2016). An example of
overproduction would be a patient who is intubated receiving a tray of food during
meal delivery in the hospital. This patient would be unable to consume the food,
therefore creating an unnecessary overproduction waste.

Over Processing
Over processing is defined as doing more work than is needed to achieve a task
(Health Sciences, 2012). When a task takes longer than expected or becomes more
invasive than anticipated it causes a domino effect. In healthcare, this waste can
impact more than just one patient. An example of over processing is ordering tests
for a patient that are not necessary. This would not only cause the patient to wait
longer for treatment and/or answers, but could also lead to a backlog of tests that
are required for other patients. In addition, the funds covering the tests (OHIP) are
being wasted when they could have more effectively been spent elsewhere.

Defects
In healthcare, defects are an ongoing issue because of possible complications that
could arise and the cost associated with the mistake. Defects can be defined as
time and material spent doing something incorrectly and later having to correct it
(Lean Manufacturing Tools, 2016). Associated with defects is the cost to have the
tools, procedure and/or form inspected. An example of a defect would be a
misdiagnosis (Lean Manufacturing Tools, 2016). Not only would this impact the
patients life, but the cost and time associated with the mistake would not need to
be spend had the defect been avoided in the beginning.

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Works Cited
Bercaw, R. (2012). Taking improvement from the assembly line to healthcare: The
application of lean within the healthcare industry. Boca Raton: Taylor & Francis.
CIHI. (2015). Canadian preliminary core patient-reported experience measures.
Retrieved from
https://www.cihi.ca/sites/default/files/document/patient_reported_experience_
measure_tech
notes_enweb.pdf
CIHI. (2016). patient experience. Retrieved from https://www.cihi.ca/en/healthsystemperformance/quality-of-care-and-outcomes/patient-experience
Crawford, M. (2016). 5 Lean Principles Every Engineer Should Know. ASME.
Retrieved from
https://www.asme.org/engineering-topics/articles/manufacturing-design/5lean-principlesevery-should-know

Eba (2016). Lean Manufacturing Principles. Educational Business Articles. Retrieved

from http://www.educational-business-articles.com/lean-manufacturing-principles/

Lean Leadership. (2012, September 17). 7 wastes: common healthcare examples.

Retrieved from
http://healthsciences.utah.edu/lean/slides/handout_sj.pdf
Lean Manufacturing Tools. (2016, January). 7 wastes of lean manufacturing.
Retrieved from
http://leanmanufacturingtools.org/77/the-seven-wastes-7mudas/

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Lean Manufacturing Tools (2016). Value Add vs Non-Value Adding Processes. Lean
Manufacturing Tools.
Retrieved from
http://leanmanufacturingtools.org/89/value-add-vs-non-value-adding- processes/

Mahalik, P. (2016). Learning to Think Lean: Six Steps with Review Points. Six Sigma.
Retrieved from
https://www.isixsigma.com/methodology/leanmethodology/learning-think-lean-six-steps- review-points/

Millard, M. (2016, March 10). The 7 wastes of lean in healthcare. Retrieved from
https://blog.kainexus.com/improvement-disciplines/lean/7-wastes-of-lean-inhealthcare