[MUSIC] Good morning, we'd like to talk about identifying waste in any process that you might be looking to improve. There are Impacts of waste, of course. Now, those can be money and time, important components in how they are interrelated, because anything that takes time is going to cost money in our lives. Additionally, there's the concept of value, that if you are impacting that cost and that time, it's valued to your customers if they have any experience of waste when they are interacting with your process. So safety is also a key component in healthcare, that every time there is a waste, it is going to reduce our ability to take care of our patients and to perform the necessary functions to serve our communities by taking up too much time. Access to care is that most important component at the end, that if it takes the time, it will also reduce our ability to see as many patients as possible, given our limited resources that we have in many of our facilities. Now, if you look at those waste concepts, what is waste? Waste is really, in a broader sense, an activity that just does not add value. And that value has to be defined only by the customer, but then who is the customer? The customer is whoever is the recipient, not the deliverer, of that service, so the customer in patient care is, of course, the patient. And what is value? It is what the customer is willing to pay for. It may not be something that we are performing just to improve the chances of not harming someone. We look for value to be something that goes forward in creating a better patient, a better experience, improving their health. So between waste and value, now we have to identify what the wastes are. And the word for waste, in lean terminology, is muda. It almost sounds bad when you say it, muda. So that is the term that you are going to hear in many places with lean conversations. And those seven wastes, those mudas, were defined in the 1940s by Taiichi Ohno, who is the father of lean. And these are the same wastes as in the beginning. Each organization might modify that acronym a little bit just to have a different set of letters, but the meanings behind them are consistent since their beginning. Let's just quickly go through them. Defects, of course, anytime there's a defect, it's going to need to be redone, so it is going to be a waste. Overproduction, anything that you have produced that was not needed is going to be something that is going to be thrown away, again, a waste. Motion, think about hunting and gathering. If you are searching, even for your keys, that is a waste of motion because it has no benefit. Over-processing, if you are doing the same thing over and over, double-checking, triple-checking, that over-processing is waste. Waiting, I'm not even thinking of a better way to think of waste than waiting, which we have in so many of our places in healthcare. Inventory, I know that in healthcare, we have issues that we are afraid of running out of some supplies or medication. But everywhere you look, we do have too much inventory. We can always do a little bit less. We don't have enough space to keep all the inventory. And then once we are spreading it throughout the organization or the building, then we lose it, and then we waste it. Inventory is a problem, just like the others. Transportation, the last of the wastes, is if you think about being a patient in a hospital, and being moved from location to location. Even if you're going from waiting room to waiting room, there is no benefit to that, it is pure waste. So let's have some examples for each one of those. Again, defects are errors, mistakes, missing items, like the wristband, redraws, anything that is part of the patient experience. In overproducing, we have orders that are unnecessary, things that happened in the course of the care that are not needed, but they are performed anyway. Motion, the hunting and gathering, as I said. Searching for a wheelchair or searching for a pillow, something that takes time for the provider, or for the nurse, or anyone else looking for something and can't find it. Overproduction is an effort that doesn't add value, because you are retesting, rescheduling the OR. Any of those things are just, again, a waste. Waiting, I've had the discussion before that a delay between any activity is a waste of time for the patient, and the providers as well. Inventory is the excess work of either finding it, storing it, stacking it, any of the materials or supplies. And transportation, moving items, or people, or even information does not add value. If you look at those seven wastes as a group, it is most important to identify that it is a waste. You really don't need to spend a lot of time and effort fighting over which particular type of waste it is. Just identifying it is the most important thing. Now, when you have all of those concepts of waste, you really need to go to your place of work, go to your gemba where things are happening. And you need to do a waste walk to identify and find them so that then you can come to ways to eliminate each of them. So the practice is to go and see waste in those areas. You physically have to go there, then you have to, when you go, observe with big eyes and a small mouth. Don't constantly be making changes on the fly, just being a fly on the wall, being an observer. Now, after you have those observers, do as many of those observations as you can, go back many times. You have to have this habit of being able to be sensitized to the waste with time. And then once you have all of those observations and recordings done, then you can take them back and put them on a DOMOWIT chart. And so you can look at those errors, and wastes, and inventory problems, whatever. And see if those errors and wastes are speaking to you, that you have found everything. So here's an example in the DOMOWIT chart. If you go to your doctor, and you're going through the normal steps of registration, vitals, exam, and discharge. If you were observing all of the wastes, each one of those X's is an indicator that someone has identified that type of waste in each one of those steps. If you put all these into one chart, then hopefully the white space will speak for you, that that little column where it has no waste is in inventory. It may be that there isn't an inventory waste in that set of processes, but it may be that you just missed it and have not been sensitized to it. So that might give you an opportunity to go back and to make sure that you didn't miss anything in all of your observations. So with all of these ways identified, and now categorized, you can go forward and think about ways to eliminate them now that they're identified.
