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visit MIT OpenCourseWare at ocw.mit.edu. PROFESSOR: First, I
want, on a personal note, I went through the
course this summer and I'm really happy to
see so many health care, or so many attending from the
health care sector, because I think in the future
it's going to be quite impossible to function
in good structures without knowing something
about this process improvement, Lean Six Sigma. Because otherwise, I
don't think that you're going to be able to contribute
in a good and productive manner. So, really important, and
very nice to see you all here. All right. At the end of this, you'll be
able to sketch a basic value stream map, demonstrate some
basic analysis of those maps, and then recognize some steps
for process improvement using your value stream map. You recognize this? Back to the hot dog stand. And it may not look exactly
like the ones you made. So, starts with
taking the order, placing it in the "in" tray. Get the order, cook the
dogs, put them in the bun, and wrap them at the fruit. And then it's a
question of, do they need another hot dog or not? If they don't, they will
go up to the order out, if they do then you go over. Check if the order is OK. At the beverage delivered
to the customer, and the customer leaves
with their hot dogs. So, value, as we think
about it in Lean, is really value
for the customer. it's not value for us. And in particular
in health care, we know so much about
the engineering side. But in health care we really
have a difficult time coming to terms with this. We struggle with it, because
it is oftentimes about, how do things work best
for us, and not so much, how do things work
best for the patients? If it was the other
way, we probably wouldn't have waiting rooms. We do have waiting rooms. We have waiting rooms all over. In fact, I work in the
Emergency Department over at BI, and we have recently
decided that we're going to make it
a formal process to open our waiting room. Because we don't really
want it, and it's going to be paged out
as a formal process, as a formal step, that
now we decide we open it, and we will not
have it open if we have any open beds
in the Department, because it doesn't
make any sense. Anyway, that would be
value for the customer. Identify the value
stream, map out the end to end linkages between
the processes, what goes on. Then we focus on
making flow continuous from one end to the other. Pull, that we heard
about earlier on. Let the customer
pull the value rather than us producing a whole bunch
of things that then get piled up and some of it gets wasted. Then we do it over
and over again, because we're never really
going to reach perfection. But we're going to strive
for the perfection. So value stream mapping, it's a
tool to improve our processes, our whole production,
by identifying steps that add value. And also by identifying
waste in our processes. We follow the value
creation process, we talked about, from
one end to the other. And you need to go
to Gemba to get out there and see what happens. You can't sit in an office-- you can sit in an
office and you can think that you know what
is actually happening. But in reality you don't. I have some examples,
I'll get to that a little later, from our final
hospital, if we have the time. But when you go and look at
what actually takes place, you get surprised,
even in the environment that you work in yourself. Because we all think that
we have the solutions to the problems that we
encounter, and sometimes we do, and sometimes we actually don't. The value stream map is the
process maps that we've done. Some of you have
already added your data. It can be time data, it can
be quality data, inventory, resources, people,
things, and whatever else. But don't clot your
maps with things that are not really useful for you. So there are some steps to
creating these values to be maps, and the first is to
define customer value, and then the process. And we can discuss
what customer value is. That is a debate you can
see among yourselves here with the maps that
you've created. You did not all
agree on what adds value, what
customers potentially would be willing to pay for. An example. We've just done a Lean project
with our registration people. Patients need to be
registered, right? And is that a value
added process? We weren't quite
agreeing on that, at least not initially, because
you can say, well, I mean, patients, they don't care. But in fact, if you
dig a little deeper they probably do, because
if you aren't registered, your visit is not
linked to your record, and then it's not
part of your history. And then it's hard to
tie everything together. So identify the value
added and the waste steps is the next one. And then, in order
to change things for the better in
the future, you need to understand what
you're currently doing. So you do a map of
the current state. Where are we now? And then you analyze that map
and you find opportunities for improving things. You can look at bottlenecks,
you can look at work load balancing, and you can have
that as an open discussion of what can you make better. And now you've just heard
the module on people. And that's actually interesting. If you involve everybody
in this process, you can get a lot of
good synergy in it. And by involving
some of the skeptics you can actually win
them over sometimes. We've done that too,
surprisingly enough. But it is possible. Then you use that to create
your future state map, and then you make an
action plan for how you are going to get there. And I think we'll get to that on
day three, in the A3 thinking. All right, we're back to this
one that follows the value creation process. And you have, in
your groups, assessed the values and the wastes
for each of the processes. And now it's time
to add some data. I think that we'll
just go with the map that you had handed out, all
the data should be on it. Time's in seconds, and there's
some quality measurements as well, because
the processes there weren't perfect the
whole way through, right? It was 100% every time. We know our demand, our
current demand at least, for the 50 customers. And we know how long
we're open, so we know how long time we have to
fulfill the orders as they are. The takt time is
our available times. It's 4 hours time 60 minutes,
that should be 240 minutes. And the demand is 50 customers. So we have 4.8, or 288
seconds per customer. We also know that the cycle
time from what we added up is actually 446 seconds. So we can all understand that
they're pretty stressed, right, because they're spending more
time than they really have. And then there's the
alternative calculation where you've taken the set out
and the clean out time out. Some of you might have
been thinking about that and done that when
things are slow. And that gives you a
little shorter takt time. But there's still an imbalance
between the takt time and the cycle time. So you're still in the negative. But you have two workers. So the question is, can
you meet their demands? All right. If you take the second
handout that you got, with the
different processes on, write down in your groups. You have 10 minutes, you'll
get a warning after 7. Write down who is doing what,
how much time they're spending, and then as well whether it's
value added or non value added. All right, we're going
to start off here because you look very ready. You're starting to search
for solutions, here. Sasha, how much is
he working, or she. GUEST SPEAKER 1: 159, OK. Andy? 224. OK, now, Wait and Neither
should be the same. So let's look at value
added, non value added. 209, 174, 63 wait. All right, that
seems reasonable. Let's see if other folks agree. And again, just like
last time, these things are kind of open
to interpretation. Hopefully, actually, this
mix is pretty prescribed, but this is up to your judgment. So we're expecting some
different answers here. So this time we've got,
basically because we constrained the problem down,
these answers tend to agree, these are still, people
have different opinions about different things. And so we have a
fair range there. But it does look
like, as an over all, that this isn't a bad process. There's more value added
than non value added. So that's pretty good, actually. So these people are
not wasting their time. But there is a substantial
fraction of non value added and wait time
in the process. And what can we say
about Sasha and Andy? Balanced process? No. That may be an
opportunity to do better, and gets right at
this issue of, well, our cycle time, our
takt time, the time that each individual
person is working don't match up right now. So back to Bo, and we'll see
where we can go from here. PROFESSOR: And you
could also say, with the differences
on the value added and the non
value added time, what would you do to understand
that better, now we're sitting and doing it on paper here? AUDIENCE: I can't
answer that question. [LAUGHTER] I have another comment. We watch the process. PROFESSOR: Yeah. AUDIENCE: You could go
and watch the process. PROFESSOR: Go and
watch the process. And how about talking to
the people there, right? The customers. AUDIENCE: That brings me to
that, in CQI you would give it, I can't actually
remember now, it's been a while since
I've implemented these. But we would give it a number. So that not every unit of
Andy and Sasha would equal 1. And I think maybe we would
value some of her chit chat as personal relations that
actually people may be coming back to get the hot dogs. Not because hot dogs
are great to eat and they love these hot dogs,
but she brings them back. So her time spent chatting,
although taking up time, may be given more than
one, or his less than 1. So they may be
doing balanced work if you look at it
on a deeper level. PROFESSOR: At least
that's an assumption until you have clarified
with the customers whether this is really
something that they value. GUEST SPEAKER 1: That's
actually a comment that can be taken in a couple
of different directions, right. Right now this is absolute
time spent doing everything. So based on this, should
Sasha chit chat more or less? Does it do any good
if she does less? No, actually it solves
nothing and makes the customers annoyed. So maybe more is
the answer there. That's right. Yeah, and now this is
just the time, right. You're also getting into sort
of a value judgment of who is doing more for the
company, and that's dangerous, so we won't go there very far. But certainly it's not
hurting anything for her to keep doing that right
now, because she's actually underutilized compared to Andy. OK, so we're actually
going to do some numbers on that thought. PROFESSOR: Yeah, and we are
going to do, let's see here. GUEST SPEAKER 1:
Click, there we go. PROFESSOR: If we look at
Sasha's tasks, we all got 159. 50 orders. So she is working 133 minutes
out of the 240 minutes available. And Andy was 224
seconds per order. So working effectively
187 minutes out of the 240 minutes available. And so their work time,
or their workload. Sasha's working 55%
of the available time and Andy is 78 of
the available time. And their capacity, if
you, let me see here, the touch time per order, if
you take the waiting time out, should be 224 seconds, which
is defined by the one that's the slowest, which is Andy. OK. So if you say that's 224. So they should be able
to serve 64 customers. GUEST SPEAKER 1: That's
if Andy maxes out. PROFESSOR: Yeah, working
100% of the available time. That's not always a good idea. It's hard, at least. So we're not going to talk
about the variations right now, we're going to do that later. GUEST SPEAKER 1: We
got a question here? AUDIENCE: Yes. Just looking at this
data, if we were analyzing this company saying, what can
we do to create a Lean process. Would our initial
thought be, OK, what are the tasks
that aren't needed and how do you delete
them from the process? Or would we say, OK, what are
the tasks that Andy's currently doing that we could, perhaps,
reallocate to Sasha such that we have a more continuous
flow to the process? PROFESSOR: That is
what you are going to be discussing in the next
exercise that is coming up here in a minute or two. And then you can determine
what you find more feasible. GUEST SPEAKER 1: Although
you have a good point there, because the thing
you said second is the one that's in the exercise. The thing you said
first gets at that issue of, well, let's make
Sasha more efficient. Or not, because as we
get a little deeper into the analysis, we find
that that's not actually going to help us. So hold the rest
of that thought. PROFESSOR: But the
best first step is to do what you've
done now and analyze what's actually going on. We saw that our current
production, the 50 customers, is actually a little
less than they can produce the
way they're doing, or the way they
could be doing things if they were working 100%. So they need to improve
their processes in order to meet their growing demand. They're a popular stand. Whether it's the talking,
the chit chatting, or the quality of the hot dogs,
we don't know at this point. But we can see that they're
underutilized 55% to 78%. And their work is
not balanced, either, and their cycle
time per customer is too long, regardless
of how you calculate it. So you should be able to shorten
that by looking at it, OK. And that is your next job. Help them figure out
what they can improve. How can they improve
their utilization? How can they reduce
their cycle times? So now you can change the
order that they do things in. And find out what they need
to do in order to serve 75 customers and 100 customers. So this is 10 minutes. GUEST SPEAKER 1: OK, so
this is a brainstorm. That's actually sort of
a technical term, right. Have people gone through
brainstorming exercises before? AUDIENCE: Yeah. GUEST SPEAKER 1: So
it's interesting, the medical people
are saying yes. Engineers? Yeah, OK. So you're throwing
ideas out there, no idea is rejected
at this point. Let's just collect thoughts. PROFESSOR: Let's
start back up and hear if you have some suggestions
for changes, improvement. Go ahead. AUDIENCE: So we started to look
at the process of just taking the orders, because
it seemed like that was where a lot
of inefficiencies were disseminating from. Or rather, a lot of the
hold ups, from our chart, were coming from. So we thought that
it might actually be a better idea if
there were precreated tickets, where a customer
could write in their name, write in what they want. And then give it to Sasha. And then while Sasha was
filling their drink order, they could pay her. And that would get rid of her
adding the beverage later on, her rechecking the order,
some of those inefficiencies. The other bird that it kills is
that, while wait time, capital wait time, might not
change initially, the perceived wait time would
change for the customer. Because if you hand them
the drink ahead of time they have the perception that,
hey, things are coming along. GUEST SPEAKER 1: All
right, yeah, that's good. They always bring
the wine first. AUDIENCE: Get your drink first. PROFESSOR: So they can
sell you an extra glass. GUEST SPEAKER 1:
Yeah, that's right. It's already gone by
the time dinner comes. PROFESSOR: Any
other suggestions? Want to go, back table? Yeah? AUDIENCE: So we've thought,
for steps number 10 and 11, with some different preparation
work, such as keeping double the amount
of stocked items and double the amount of trash
bins, et cetera, condiments, they could cut that
time in half and only do that work every two hours. PROFESSOR: Right, OK. AUDIENCE: Since Sasha is not the
one actually picking the order, she's just filling
order tickets, she ought to help Andy
out in the kitchen, by being the one to do
part of steps 4 and 5. Yeah. If Andy puts the dog in the
dinner, wraps it in foil, she can just add
the fruits of choice and put it in a
selling container. That way she doesn't have
to recheck in step 7, because she's the one
actually doing it. So when we recalculate
the numbers for that, originally right now it's 50
of value added time, 36 of not. From 4 to 8 is 36 of non value
time and 33 of wait time. When we change what they're
doing in each part of that, so that he's just doing the
dogs and she's doing everything else, and we take out that
sitting on the counter wait time, it all becomes
80 of value added time. So we have no non value added
time anymore, and no wait time. So we've eliminated all that. And we have 80 of value, versus
the 50 that's originally there. PROFESSOR: OK. Does it change any of the times
in between the two of them? AUDIENCE: Yeah, it would. PROFESSOR: Sasha is
going to work more? AUDIENCE: A little bit more. 20 seconds more. She was originally, from 4
to 7, 21, and now she's 40. PROFESSOR: OK. So those are seconds
that is going from Andy? AUDIENCE: From Andy to Sasha. We had a similar
suggestion where Sasha would do some of the
work of filling the container. But we kind of envisioned it
as a flow or a [INAUDIBLE],, and that she would
fill the containers and then Andy could
just look down and see how many containers
are just waiting for him. And then he could just put
the hot dogs in, wrap them up, and then you have a bag. They would already
have the fruit. She would put the
bun in the foil. GUEST SPEAKER 1: I like that. Very nice. PROFESSOR: Other suggestions? AUDIENCE: We have the customers
getting their own beverage and putting their
own toppings on. That cuts down on time, and
it also reduces the errors. You're picking your hot
dog, you can't screw it up. And then, the customer
knows what they want. And it would also give them
more control over particulars, ketchup versus
mustard, or whatever. And we also have them
getting their own fruit. PROFESSOR: All right, very good. More suggestions? All right, so, what
you have done here is, you have rearranged
some of your processes. You have changed the workload in
between the two in the business here as well. So that they're
working more even, or have a more even workload. And you're involving
the customers, saying, customers can do some
stuff themselves. They can pick up the fruit,
they can pick up the drink. Don't need to have someone
doing that for them. Right. And some of you focused on
reducing the, or involving the customers, to make the
wait time go down as well. I like that. What else do we-- GUEST SPEAKER 1: So did
anybody go to Fresco's today? That lunch place, a
little deli, catty corner. I guess not, no. they have a great system
there, which is apocryphal. I'm not sure if
this story is true. But I know one of the
Saturday Night Live people actually lived in
Cambridge for a long time. It's alleged to be the
"cheeseburger cheeseburger" inspiration. You say what you want
in a yell, right. There's no ticket,
there's no, you know. And then they yell back, to make
sure they understood the order. BLT small fries! BLT small fries! Takes one second to
say, low error rate. High training, that guy has got
to keep it in his head, right. Yeah, so, most of the
other possibilities are definitely up
here, some good ideas. And this part, by the way,
is also pretty realistic, in the sense that this is art. You don't know the answers,
none of these techniques tell you the answer. What they do is
frame the problem and help you understand
what problems you're trying to solve. You're not trying to
make Sasha stop chatting. You're trying to improve
the overall performance of the system. One question we have with this
is that not all the time was allocated, and it's unclear
exactly why the wait times are the way they are. The question of
the flow of orders, and so maybe from 11 to
1 they are at capacity, and there's just no
demand 10 to 11 or 1 to 2. So there might not
even be the opportunity to increase the capacity
to hire another person or to do something different. PROFESSOR: And that's
the kind of thing you would find out by
actually going and observing the process, rather than
us sitting in a classroom here and saying, this
is the way it is. GUEST SPEAKER 1: That's right. On the other hand,
there are things that always help, even if there
is that issue of, maybe some of the time they're slammed. Balancing always helps. Eliminating non value
added steps always helps. So there are some things
you can do confidently. There are other
things that you may have to actually go and see,
well does this make sense. Will this work. And possibly even
experiment with, try it, see how it goes the
next couple of days. PROFESSOR: So, a few things
that we thought about. The "in" order, where
it's sitting, what is it, 30 seconds, here in step 2. And the "out" order. Take those away. Inspection, we heard
earlier, that inspection doesn't add much. GUEST SPEAKER 1: I
really like this. I don't think I've
heard that one before. The thought of consolidating
Sasha's work and the inspection into one step. So then you get the quality,
but there's no extra step. So, that's a good solution
to not apriori eliminate inspection, which might
lead to quality issues. PROFESSOR: And balance the work
you've already done, as well. Now we're down here to
create a future state map to visualize how we want
this to look in the future. And then, create the
action plan for how you're going to achieve your change. Because talk alone won't do it. So, make the map, create a
plan, set some deadlines, and assign some
responsibilities for who's going to do what
to change things. So the value stream map
is useful to visualize what is going on in the
interactions and the flows, and gives you the linkages
between your information and your product flows. It gives you a
language that you can talk about with the ones
who are in the group. And you can identify your
constraints and capacities and wastes. GUEST SPEAKER 1: Do
you have a question? AUDIENCE: I just have a
question about the process. Maybe I'm having
difficulty visualizing it. But it seems like we're
following the hot dog in a linear way, whereas it
seems like some of this stuff happens simultaneously. So I'm not sure, some
of the seconds overlap. It's not like Sasha's
seconds happen only after Andy's seconds happen. So that's a little
bit hard for me to understand in
this flow model. PROFESSOR: And that,
as I perceive it, that can sometimes be a
problem to look at it like that in a process map. And I have a slide a
little bit later where you can look at
swim lanes, as well. Because it can depend
on who is doing what. And that can happen at
the same time as well. So you're absolutely right. They do happen simultaneously. GUEST SPEAKER 1:
The classic issue, which you're keying on, I think,
is like, in a real hot dog stand there would be a bunch
of hot dogs on the grill that would be cooking
at the same time that all this other
stuff is going on, right. So there are some processes
that are maybe out of phase. And that's true. That's a real issue. The map doesn't
catch that very well. That issue of some
things happening out of phase with other things. But it's a tool. It's not a perfect tool. It doesn't solve all
of your problems. PROFESSOR: All right. So, tips for creating it,
involves the entire team. Everybody who's involved
in these processes need to be involved. It can't only be a
few people that maybe have management positions. You need to have the
people doing the work come and be involved in this. Because they're the ones who
understand the work the best, and can come up with
the best suggestions for how to change it. And you need to
actually go to Gemba, go and see, use the post it
notes like you've done now, on your map, put that on. And then you can
use your symbols, you can use whatever
you pretty much like. There are some that are
more use than others. But however you want
to do it as long as you make sure you
have a common language. Here's a little bit
about the swim lanes. Because you can have
different providers, or different processes, at the
same time in an organization. And you can try to
map it out like this. So, things that take
place at the same time. Or you can have the castle wall,
with production times and wait times added up in the end. Have your wait times and
your productive times. So there are many
ways, and there are some resources, where you
can learn a whole lot more about this. GUEST SPEAKER 2: Can
I say one more thing? When you do a value
stream map, make sure that you bring it to the
people doing the work to get their validation. Say, did I leave anything
out, did I forget anything. Because oftentimes,
you miss something. And they could say, oh, but
you forgot that we do this. And I think that's really
important, because then it gets them to buy into what
you're doing, as well. GUEST SPEAKER 3: And
even more strongly, you should have those people
participating in the creating of the value stream map. PROFESSOR: That's
actually what we do at BI. The ones doing the
processes, and it's often from different provider
groups, we involve them, we invite them, and we help
them come up with this. GUEST SPEAKER 2: And then
post them on the floor, so they can see them
and they comment. PROFESSOR: A good technique for
all of these things that you do is, take pictures of these
things, and you can post them or you can email them
out to people, and say, this is what we
found, please give us if you have any comments. GUEST SPEAKER 2: This is
also a really good link between administration
and front line workers, because I know in
most hospitals, the administrators take
turns walking around to visit the floors. And a lot of them are
not clinical, might be the CFO or something. They come around, they go,
how are you doing today, do you need anything,
how are you doing today, do you need anything? But if you have a value
stream map posted, they can go to that map
and you can discuss what you're working on together. And it just brings it
to a different level. We call it Board Walks. Give them something to look at. GUEST SPEAKER 4: And the same
is true in an engineering environment. Not just health care. GUEST SPEAKER 2: Absolutely. PROFESSOR: And for
health care, if you dare, go and find a patient who's
arriving to your emergency department, to your area of
work, wherever that may be. Follow that patient. If you're a phlebotomist, go
find a patient registering for their blood draw. Follow them the whole
way through, OK. Take a chill pill
before you do it, because at least in my field,
in the emergency department, I've tried. And I think IHI calls
it "The Walk Of Shame". And it really is. But it is important,
because otherwise you will not understand. Most of us, I mean,
we have different ways into the health care system. Again that is my perspective. So let's be honest, my wait time
in my own emergency department is probably not going to be
the same as somebody else's. And another thing is, I
don't have the same need to frequent an emergency
department, right. There are things I
can just fix myself. But go, find a patient,
ask them politely if you can follow them
for their journey. And then stick with it, take
notes, bring your stopwatch.
