5S in Hospitals Workshop

Invited presentation prior to Kaizen Even at the Allegheny Regional Hospital in Low Moor, VA.

December 2011

1. 5S Training Created for LewisGale Hospital at Alleghany Kaizen Event Team Pablo F. C árdenas Orlandini, PhD Student Virginia Tech December 2, 2011

2. Event kickoff Goals of event Hospital survey results 5s training Overview of 5S audit tool Ground rules of event Brainstorming activity Planning home locations Implementing 5S method Kaizen Event Agenda

3. Remove items from the hallway Reduce unnecessary supplies Reduce the storage footprint Create logical system of storage that anyone can understand Bring ownership to the OR staff Goals of the Kaizen Event

4. Ground Rules of the Kaizen Event Start and end breaks on time Everyone’s opinion counts Speak up with ideas, thoughts, and comments One operating room must always be available

5. Basic 5S Training 5S What is 5S and why do we want to do it?

6. 5S Definition Simple but highly effective set of techniques that remove waste from your work environment through: Better workplace organization Visual communication and management Standardization General cleanliness

7. Sort Organization: distinguish between what is necessary and what less essential, removing unnecessary items or tools from the workplace. Straighten Neatness: item are put where they best meet their functional purposes. There is a place for everything and everything is in its place. Shine Cleanliness: inspection for and elimination of waste, dirt, and damage. Standardize Uniformity: maintain known and agreed upon conditions . Apply methods consistently and revisit them frequently. Sustain Discipline: practice the habit of doing what is required. Maintain and continually improve on 5S practices. Definition of Each S

8. What are the issues in this work environment?

9. What Can 5S Do For the Alleghany Hospital OR? Eliminates the need to search for items Better defined flow of materials and information Modifies the appearance of the workplace, conveying a more professional image Persistent and continuous productivity improvements Reduces clutter, waste and the probability of errors Reduced turnaround time Increases worker’s morale and pride A safer and healthier OR!

10. Breaking Down Each S

11. #1: SORT: “Do I really need this [many] here?” Keep only what is necessary in the work area. Needed items are sorted by frequency of use . Store often used items an easily accessible area close to the point of use store infrequently used items away from the work area Proper quantities must be determined. Elimination of unnecessary items

12. SORT Eliminates Clutter!!! Accumulation of unnecessary items often go unnoticed and this results in clutter. This clutter creates an obstacle course to get needed items. Valuable floor space disappears because of clutter. Clutter hides problems such as missing items , defective equipment , outdated medications and supplies .

13. Identifying and visually labeling unnecessary items for disposal Allows everybody to approve the move, the removal, and the categorization of items. Includes information such as, department, date tagged, the name of the person tagging, disposition, the asset code, and serial number (for accounting purposes ). SORT Strategies: Red Tagging

14. SORT Strategies: Red Tagging

15. SORT Strategies: Red Tagging

16. Removing unnecessary items: Differentiating between waste, donations, items to move to other locations in the hospital or to the warehouse SORT Strategies: Differentiating Unneeded Items Donations Waste Relocation

17. SORT Example: Donations Unused shelves given to hospital employees

18. SORT Example: Item Relocation Bins are removed from the workspace and moved to different sections of the hospital

19. SORT Example: Disposal of Expired Items Expired scrub brushes Expired 9/2008

20. Some cabinets may be full of extraneous items All of t hese can be removed The cabinets are emptied! After Before SORT Example: Elimination of Clutter

21. SORT Example: Checking the System Employee looks up the usage of items in the system: He finds multiple items that aren’t used, or expired, throwing away or relocating them

22. SORT Example: Adjustment of Item Quantity Adjusting par-levels and warehousing overstock items

23. SORT In Action!

24. SORT Reminder The goal of SORT is not to throw away things, but to remove unnecessary items from the work area . Also consider: Donating Moving to other departments Warehouse for future usage

25. #2: STRAIGHTEN: A Place for Everything STOP : Do not proceed to this step unless SORT has been completed. “A place for everything, and everything in its place.” Ultimate objective: Even someone not familiar with the area should be able to easily find, use and return something .

26. Based on visual management Labeling Signals Color coding Shadow boxes Discipline squares Distribution of i tems by location Arrange by frequency of use Group like items together Group items t ogether that are used together Arrange in natural order STRAIGHTEN Strategies

27. Visual Indicators Outlining /Foot-Printing Borders Home and Return Addresses Patient Record Stickers Visual Signals Nurse call lights Color Coding Visual Controls Exact Bin Sizes Visual Guarantees Quick-connect fittings for different gases eliminating the possibility of using the wrong gas. STRAIGHTEN Strategies: Visual Management

28. STRAIGHTEN Strategies: Visual Management Comprehensive labeling.

29. STRAIGHTEN Strategies: Visual Management Applying color-coded twist ties to equipment to know where to return equipment to.

30. Kanban – Sign board Essentially, the card is sent to the supplier when the item has reached its minimum. The card is sent back from the supplier when the order is filled. There is a buffer supply to account for the time it takes for the supplier to fulfill the order. Signals that an item requires replenishing. Can be a simple card, or any time of signal May include : Item Name Part Number When and how many are needed Where the item is to be delivered Contact name and phone number STRAIGHTEN Strategies: Kanban

31. Use two bins for supplies. When one bin is finished, it gets moved to a designated are so the storeroom clerk can order more. The second bin is used as the buffer . STRAIGHTEN Strategies: Two-Bin System Before After

32. Implementation of the Two-Bin System 1 1 1 2 2 2 Start picking from the left bin Once you run out of items from the left side, pick from the buffer Now it’s time to order more and replenish!

33. Applying tape on the floor to create equipment layout. STRAIGHTEN Strategies: Discipline Squares

34. STRAIGHTEN Strategies: Discipline Squares Before No visual indication regarding location of equipment Disorganized IV Stands and Cylinders

35. STRAIGHTEN Strategies: Discipline Squares After Discipline Squares and labeling as a visual management method Organized IV Stands and Cylinders Each equipment is labeled and has a home location

36. After In-Process Before STRAIGHTEN Strategies: Item Put together by Functionality This cabinet has a few random items Idea: adapt it to hold the biggest possible amount of related items Items were relocated, disposed or donated Swan Items are put together! All Swan Items are now in the same cabinet and in the same quantity

37. STRAIGHTEN Strategies: Rearrangement of Supplies Complete rearrangement of supplies via consolidation, and process flow improvement.

38. STRAIGHTEN Strategies: Rearrangement of Equipment Clearing and rearranging equipment and shelves.

39. STRAIGHTEN Example: Better use of Vertical Space Using PVC pipes to create additional storage for extra long items.

40. STRAIGHTEN Example: Better use of Vertical Space Before After Information material using half of the space Items that go together are kept in the same cabinet Items were moved to different cabinets

41. STRAIGHTEN Example: Better Organization of Cabinets Before After Expired Items removed Items relocated to other cabinets All Pacemakers put together Special Procedure Items placed near each other General Supplies brought from other cabinets

42. STRAIGHTEN Example: Better Organization of Drawers Before After Not functional Items disposed Items brought from cabinets Surgical Tools organized in one drawer Special Procedure Items organized in other drawer Special Procedure Items brought from cabinets Blood Pressure Items moved to other drawers

43. STRAIGHTEN Example: Implementing Visual Aids Old and not corresponding labels Unnecessary document Old attachments removed After Before List describes Par Items contained

44. STRAIGHTEN Example: Using Labels, Pictures and Checklists Before How can we know where the items are supposed to be kept within a cabinet When should the items be replenished Are there minimum and maximum levels ? ? ?

45. STRAIGHTEN Example: Using Labels, Pictures and Checklists After Image and text indicating how the cabinet should be set for optimal usage Picture for best layout Minimum and maximum levels for each item An erasable checklist works as a trigger for replenishment Labels below each item

46. STRAIGHTEN In Action!

47. #3: SHINE: “Like New!” The workplace should be clean and bright, a place where people enjoy working. If you can’t get something clean, then paint it, replace it, or cover it. Morale booster !!

48. SHINE Strategies Clean equipment and work surfaces thoroughly Inspect for hidden damage and deterioration Make everything “like new” Find ways to prevent things from getting dirty. e.g. Plexiglass shield. Have proper cleaning tools and supplies Have assignments, checklists, schedules, and maps

49. SHINE Examples A medication room before and after the first three S’s

50. SHINE In Action!

51. #4: STANDARDIZE: Constant Application Helps maintain the gains achieved by the first three S’s . Develop a set of best practices and make sure everyone knows and agrees with them. This phase involves communication and training. People must be instructed to take only from the non-buffer bins. Nurses must separate the empty bins and the clerk should know to send in an order when the empty bin is pulled. Everyone is accountable.

52. Prevention Code of Conduct Every job has duties that use SORT, STRAIGHTEN, and SHINE Common duties to keep common areas in shape e.g., break room Best Methods Weekly 5S departmental tours Estimate Time Training Analysis: Ask “Why Not?” Checklists/Audits STANDARDIZE Strategies

53. #5: SUSTAIN: Continuous Improvement Developing new habits An ongoing phase to ensure everything is maintained in order and up-to-date Also responsibility of management – set an example Without this discipline, all the previous S’s work will be lost It may be very easy to slip back into old habits.

54. Know what motivates you to do 5S Individual and MRH Benefits Create a sustainability plan to remind you Communication of 5S Kaizen event benefits Individual motivators Visual cues will help as well Implement the Plan on an Ongoing Basis SUSTAIN Strategies

55. SUSTAIN Strategies: Identifying Issues and Future Improvements Conducting audits of the room daily for the next few weeks to help sustain improvements.

56. SUSTAIN Strategies: 5S Audit Tool LewisGale Alleghany 5S Audit Form Audit Date:   Area: Operating Room     Person auditing:                               Category and Item Poor Marginal Good SD=Strongly Disagree D=Disagree sd =somewhat disagree sa =somewhat agree A=Agree SA=Strongly Agree SD D sd sa A SA 1-2 3-4 5-4 1 2 3 4 5 6 SAFETY Are there any trip hazards (hoses, electrical cords, etc.) in the area?   Is the life safety code being followed?   Are all items securely placed (e.g., will not fall off shelfs, carts, or cupboards)?   Are there any other work hazards in the area (sharp corners or objects, other items that could be dislodged easily, etc.)?   Are all critical areas accessible (fire extinguisher, shutoff switch, etc.)?   Are all equipment items working properly?   Are all floor areas that should be clear free of debris?   Are shelves, cupboards, or other storage locations ergonomically designed (proper height, avoiding excessive reaching, within safety restrictions, etc.)?   Are all electrical cords free of frayed areas?   SAFETY Average   SORT Are there unnecessary equipment, supplies, tooling, or materials in the area?   Are there unnecessary items stored/placed on cabinets or shelving units?   Are there obsolete or broken items, equipment, tooling, or supplies in the area?   Are sufficient quanties of supplies in the area?   Has a proactive sort initiative been conducted in the area in the last 6 months?   SORT Average  

57. SUSTAIN Strategies: 5S Audit Tool LewisGale Alleghany 5S Audit Form Audit Date:   Area: Operating Room     Person auditing:                               Category and Item Poor Marginal Good SD=Strongly Disagree D=Disagree sd=somewhat disagree sa=somewhat agree A=Agree SA=Strongly Agree SD D sd sa A SA 1-2 3-4 5-4 1 2 3 4 5 6 STRAIGHTEN Are labels and signs clear and easily readable?   Do all movable equipment and carts have a "home location" that is clearly identified?   Do all instruments and supplies have a "home location" that is clearly identified?   Are all items (equipment/carts, instruments, supplies) in their correct home locations?   Are locations for items logically organized (like items together, related items together, etc.)?   Are stacked items (supplies and equipment) sorted properly (by type, size, etc)?   Is the work area visually appealing (neat and orderly)?   Is material/physical flow in the area clearly identified?   STRAIGHTEN Average   SHINE Are cleaning materials and tools easily accessible?   Are equipment and shelving units kept clean and free of dust, dirt, and debris?   Are designated walkways free of dirt, dust, and debris?   Is the area swept and the floor clean?   Is lighting in the area good?   Are all connections, hoses, cords, covers, and lids in place and secure?   Are trash bins and scrap/recycle containers emptied on a regular basis?   SHINE Average  

58. SUSTAIN Strategies: 5S Audit Tool LewisGale Alleghany 5S Audit Form Audit Date:   Area: Operating Room     Person auditing:                               Category and Item Poor Marginal Good SD=Strongly Disagree D=Disagree sd=somewhat disagree sa=somewhat agree A=Agree SA=Strongly Agree SD D sd sa A SA 1-2 3-4 5-4 1 2 3 4 5 6 STANDARDIZE Are all home locations for items clearly documented and accessible?   Does everyone consistently put items back in their home locations?   Are storage locations consistently replenished when needed?   Are results of the previous 5S audit posted and clearly visible to all?   Have issues and areas for improvement identified during the previous 5S audit been completed?   STANDARDIZE Average   SUSTAIN Is the 5S process and progress discussed at Staff Meetings?   Is time to actively "5S" the area regularly planned and conducted?   Are people held accountable for adherence to 5S rules and policies?   Is performance on the 5S process part of supervisor's and associates' appraisals?   Overall, is the area maintaining 5S rules and discipline?   SUSTAIN Average   OVERALL Average  

59. Finally, 5s is for YOU! Clean-up and organize your work area every day so that each new day is easier and safer than the day before Share your input with the team so that the tools you need will be available, increasing your efficiency. Take a good look around...Imagine zero waste/zero confusion!

60. Thank You!