Lean Manufacturing
- In This Section:
- Overview
- Effective Work Instructions
- Lean in Healthcare
- Using Lean to Create Green Results
- Sustaining Your 5S Efforts - 6 Steps to Keep it Running Smoothly
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Four Essentials of Effective Work Instructions
This article was created by Patrick Sweeny of the Explainers and is reprinted with permission. You can view the original article and the Explainers website at http://www.explainers.com/Articles/Four-Essentials-Effective-Work-Instructions.htm
Overview: Returning the Focus to the Worker
A work instruction is a tool provided to help someone to do a job correctly. This simple statement implies that the purpose of the work instruction is quality and that the target user is the worker. Unfortunately, in many workplaces, today’s work instructions have little connection with this fundamental focus. Factories have encumbered work instructions with content that has been added to satisfy auditors, lawyers, engineers, accountants and yes, even quality managers. We’ve piled on so much extraneous material that we’ve lost sight of the intended purpose of work instructions.
Instead of providing a simple tool to do a job right, we’ve buried the work instruction under a cascade of specifications, contract requirements, revision history, references, controls, licensing provisions and engineering theory. The person who uses the work instruction has become an afterthought in favor of satisfying a licensing or certifying auditor.
If work instructions are to be practical quality tools, the worker must at least share focus with the auditor. This shift in emphasis does not require removal of the licensing and certification information that has been added to instructions. However, the procedure portion of the work instructions can be improved, often significantly, by appropriate consideration of the worker. Workers learn quickly to spot the usable portions of the work instructions and apply the appropriate material on the job.
This paper suggests a four-part criteria against which work instructions can be evaluated and improved as needed. As a first step in judging the overall effectiveness of work instructions, managers can examine their work instructions against four essential characteristics: credible, usable, accessible and consistent.
Credible: Workers Trust Them
Credible work instructions are at the heart of standardized best practices. In a workplace that’s committed to one and only one way to perform all procedures and processes, work instructions must define that standard.
When work instructions are credible, workers accept and trust them. But it’s easy for work instructions to lose their credibility. A common way to lose credibility is when standard procedure updates and changes get passed on verbally and there are consistent and regular delays in updating the written work instructions. With verbal changes, something can be missed or an individual can otherwise fail to get the correct message. In a busy workplace with frequent undocumented changes and updates, work instructions become marginalized with workers no longer trusting them as being accurate.
Work instructions also lose credibility when a supervisor initiates a change and deviates from standardized best practice. Even though the change may be an improvement, the worker is forced to make a choice, and the boss’s words are always going to win over the written work instructions. For work instructions to be credible, workers must believe that they define the one, single, proper way to perform a task.
Clear: Workers Understand Them
A clear work instruction can be quickly understood by the worker with a minimum of effort. To accommodate the typical worker, an ideal work instruction explains mostly with graphics using only minimal clarifying text. Illustrations or other graphic support should be immediately visible and the worker should not being required to go to any other location for supporting information.
Work instructions start to become unusable when they contain extraneous matter not directly related to the procedure. Also, multi-page or multi-screen work instructions that cannot be quickly and easily grasped do not meet the clarity test. Because most workers have neither the time nor the patience to struggle with unclear work instructions, they lose their practical value.
Accessible: Workers Can Get To Them
Work instructions are accessible when they can be located quickly and easily. "Quickly" means within seconds and "easily" requires a retrieval system that the worker knows, understands and trusts. An ideally accessible work instruction is displayed as a job aid in immediate full view in the workspace.
If someone with a question about the proper procedure must struggle to even locate the applicable work instruction, the typical worker will find an alternative such as trial and error, guesswork, and questioning an associate or supervisor. While these alternatives might produce the right answer, they lead to a decline in the significance and importance of the work instructions.
Consistent: They Match Worker Training
Consistent work instructions conform to a style guide developed specifically for procedures and work instructions. There must be rigid consistency of terminology so that the same word means the same thing every time. There can be no undefined acronyms and confusing technical terms. All instructions should follow the same format so that the user always knows where to find information such as required tools or control settings.
Consistent work instructions also demand that the material used for worker training is consistent with provided job aids.
Conclusion
In the absence of effective user-focused work instructions, we force the worker to employ a host of unsatisfactory alternatives including guesswork, trial and error, rumor, and tribal knowledge information transfer. The inevitable result is variation, deviation, reduced productivity and lost potential.
To achieve the desired quality benefits of standard best practice, effective work instructions need to be a fundamental first step.
Lean in Healthcare is the wave of the future. Healthcare in Minnesota is going ‘lean’
| Adopting Toyota process principles shows promise for improving |
St. Luke’s in Duluth will spend about $1.5 million later this year to modernize its cardiac catheter lab in a strategy to capture larger market share. Expensive new technology is an old story in the healthcare industry, and widely viewed as a factor in the runaway costs that are forcing many businesses to scale back or drop their group benefits for employees. But how St. Luke’s has developed its project — and is beginning to run its overall operation — represents one of the most promising mechanisms for taming healthcare inflation.
St. Luke’s, SMDC Health System and a handful of smaller healthcare providers in Northeastern Minnesota all are adopting the “lean” principles of process efficiency and quality assurance that Toyota developed after World War II to become the world’s leading auto maker. St. Luke’s two-bed cardiac catheter lab is plagued with inefficiencies common to industrial and service business processes that are designed around existing facilities rather than for efficient work flow. When St. Luke’s added the second bed in its lab, the storage area for cardiac catheter supplies and equipment was relocated to an available room across a hallway, outside the lab’s sterile area.
As a result, the lab’s nurses and technicians have to keep seldom used sterile supplies on the mobile carts within the lab, making the already cramped space there even less efficient, said registered nurse Michelle Fleming, the hospital’s patient care services director. When a physician asks support staff for a special medical item, the physical obstructions become barriers to traffic patterns, she said.
Fleming identified the bottleneck using “value-stream mapping,” a lean technique for measuring process efficiency. “There are a number of times when a tech and nurse need to get equipment. We’re making way too many trips,” she said. So many, in fact, that St. Luke’s believes it will be able to handle current cardiac catheter patient volume with one fewer technician in the new lab. “We’re not going to lay off anyone,” Fleming quickly added. “Our hope is that with the additional efficiency we’ll be able to do more procedures without adding any people.”
The healthcare industry is just beginning to adopt Toyota Production System waste reduction and process concepts to increase work capacity, reduce cost, raise worker and patient satisfaction, standardize results and to build a culture for continuous improvement. While the design of the new cardiac catheter lab is its most striking embrace of “lean,” St. Luke’s has been at it since Fall 2007, said Jo Ann Hoag, vice president, chief nursing officer and the initiative’s self-described “administrative champion.”
It began with a 2007 presentation by the customized training team at Lake Superior College to Hoag and other senior St. Luke’s managers who embraced the concept and directed 64 executives into formal lean training at the health system’s expense. Two of those executives, Education Director Linda Basara and Michael Boeselager, materials management director, were named “Lean Committee” co-chairs with a mandate to train and implement lean principles that will change how all 2,200 employees at St. Luke’s do their jobs by 2013. To date, nine classes of 16 employees across departments have been trained as trainers to spread the lean gospel systemwide.
So far, the effort has reorganized the hospital’s laboratory and the storage areas that Boeselager manages. Jennifer LaMaurea, the lab’s blood bank manager, said lean process changes have helped shrink the bank’s inventory of red blood cells on hand by “30 units at $200 per unit. Lean objectifies the process for implementing change,” she said. Boeselager said the initiative is producing a “brush fire” of process improvements. Hoag said the lean process is creating teams across departments — laboratory, emergency room, nursing units and pharmacy to name a few — to make care more patient-centered.
To measure whether the initative is making a customer service difference, St. Luke’s has commissioned PRC Associates, the Omaha-based healthcare research firm, to conduct satisfaction surveys with discharged patients. “Where we have taken this on, patients are happy with it,” Hoag said. “This is a learning process, we’re on a journey.” St. Luke’s and at least eight other healthcare providers in Northeastern Minnesota are receiving Minnesota Jobs Skills Partnership grants to implement lean from the state’s Department of Employment and Economic Development, passed through a local community/technical college. Steve Wagner, Lake Superior College’s vice president for workforce/community development, wrote the grant applications for the St. Luke’s and SMDC lean initiatives, each requiring a 3:1 match from the healthcare provider. He said St. Luke’s is receiving $288,000; SMDC, $397,000.
The SMDC lean coordinator declined a request for details about its project. Meanwhile, Gail Anderson, customized training representative at Itasca Community College, is coordinating lean grant projects underway at Grand Itasca Clinic & Hospital in Grand Rapids; Falls Memorial Hospital and Good Samaritan Nursing Home, both in International Falls; Deer River Healthcare Center; Riverwood Healthcare Center in Aitkin; and the Littlefork Medical Center clinic. “Each of these projects is customized to the institution,” she said. “Lean is very simplistic and easy to learn. Once it becomes part of the (institutional) culture, it becomes sustainable. We help develop the needs assessment and goals, and provide the curriculum to get there.” Anderson is a certified reviewer for Montana-based Lean Healthcare West, which developed the curriculum the Northeastern Minnesota healthcare providers are using to become lean.
Founder and President Cindy Jimmerson, a former trauma system developer and emergency healthcare provider, is a pioneer in applying Toyota Production System principles to the healthcare industry. She won a 2001-04 National Science Foundation grant and developed that curriculum for hospitals, clinics, nursing homes, community healthcare programs and health insurance companies. She said lean is the perfect anecdote for a healthcare system that easily wastes two-thirds of the money it consumes. “We’re spending $3 trillion annually and wasting $2 trillion, enough to insure everyone without spending an additional cent,” she said. “In the United States with all the available technology, science and education, competent healthcare workers are only as good as their ability to deliver.
“We’re swimming in money in healthcare, but it’s not being used effectively because broken processes are getting in the way,” she said. Lean can fix those processes and gets at embedded waste, she said. “If we want to be a Toyota, we need to do it differently.”
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Sustaining Your 5S Efforts
5S too often is short-lived, but these six steps can help keep it running smoothly.
5S is probably the most common lean method applied. It is seemingly simple, progress is visual, and it involves everyone. However, the average lifespan of a 5S effort is a paltry one year. This is worse than doing nothing at all. Getting the organization to put this much effort into something and then not sustain it sends the unintended message that their efforts were not valuable. It is disrespectful.
So how do you sustain the 5S efforts? The following steps include actions to take during its installation, and afterward.
1. Communicate the purpose. The purpose of 5S is not safety, discipline, engagement, tidiness, being "tour-ready" or improving efficiency. Those are benefits, but the primary purpose is to be able to spot problems quickly. Look inside a NASCAR garage, and you are likely to see the cleanest garage you've ever seen. Why? Because if there is one drop of oil on the ground, I want to know about that problem right away. I don't want to find the problem 10 laps from the finish line. I want to find that problem immediately. 5S, when done right, allows you to walk into any area and spot abnormalities easily. People need to have a clear understanding of the purpose to be able to make good decisions about its use.
2. Audit at the leadership level. Most organizations get some kind of audit and check into place. Some do it from inside the team, some from peers from other groups, and sometimes from a central team. Audits are inherently wasteful but necessary. The leadership of the organization also needs to do a form of audit. What's the purpose of their audit? It's less about accountability and more about finding systemic barriers to 5S success through direct observation and engagement. These are the problems that leaders must solve to help enable sustainable 5S.
3. Periodically change your audits. Audits can become stale and routine. When they do, they stop becoming effective. Change the audit methods periodically. You might change the scoring, change the roles, change the frequency or change the evaluation method. Audits are about seeing what's working and what's not. Sometimes you need to look from a different angle. Changing how people view the process can help them see something they missed before, as well as prevent them from taking the audits for granted.
4. During a crisis, double your audits. If an area is in the midst of a crisis, be it production or quality or anything, what is the natural reaction? Do you drop the nice-to-have audits, or do you double them? Dropping is the common reaction but the wrong one. During a crisis, you want your process as stable as possible so you can focus in on the challenge or abnormal condition causing the crisis. If 5S is truly connected to helping you maintain a stable process, then it is more important than ever to sustain it. Not only does dropping the audit during a crisis send the wrong message, it can make recovery even harder.
5. Escalate problems. If audits find breakdowns in the process but there are no consequences, then what's the point? There must be an escalation process with consequences for failures. For example, one organization knows that if an area is out of control, they run the risk of serious problems. Therefore, if you fail one audit, you have a chance to correct things. But if you fail two, your area is shut down. And management must come to the area to figure out what is going so wrong and what to do about it. There must be an escalation of breakdowns in 5S for corrective action to be taken seriously.
6. Eliminate doors and drawers. You can only solve problems of an organization when you can find them. What's the purpose of doors on cabinets and drawers? Primarily, to hide the clutter. We don't want to hide the clutter —we want to eliminate it. Eliminating doors and drawers help make observations and finding abnormalities easier.
5S is relatively simple. But simple doesn't always mean it's easy. If 5S is worth doing, it's worth doing right.
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Western manufacturers are surviving mostly on productivity growth and squeezed margins.

