Michigan Quality System

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Background on "Lean Thinking"
What is a Value Stream?
Value Stream Mapping
Drawing a Value Stream Map to Achieve Future Goals
Future State Design Questions

Internal Resources Internal to Michigan Medicine employees only


The Michigan Quality System (MQS) uses continuous quality methods and tools, grounded in the philosophy of the Toyota Way, to help us improve the way we care for patients every day. Each of us has a critical role to play to ensure that care at Michigan Medicine meets all six aims of health care:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable - not varied due to gender, ethnicity, geography, socioeconomic status

Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

The Michigan Quality System (MQS) is based on the "Lean Thinking" approach to quality improvement first developed by Toyota and now widely used in manufacturing, the service industry, and increasingly in health care. Its five core principles are:

  • specifying value from the customer's perspective
  • identifying the value stream for each product – the process by which we add value from the customer’s persective
  • making value flow without interruptions
  • letting the customer pull value from the producer
  • pursuing perfection – doing all of this every day, in all our work

The overarching mission of the Michigan Quality System (MQS) is:

“The endless transformation of waste into value from the customer’s perspective in the delivery of health care.”

Some in health care worry about the use of the term “customer,” thinking it refers to patients only, rather than to anyone affected by our work. We can also use the term “those we serve” to avoid this confusion. Customers can be either internal or external. While patients are usually our "end" customer, there are many other customers we must consider, including each other. When one department needs a piece of information from another department to perform a task, that first department is the customer. For example, when radiology needs a requisition from our physician to schedule and perform an MRI, the ordering physician is an internal customer, just as the patient is the external customer. The Michigan Quality System will consider the needs of all customers as we improve how work is processed.

The Michigan Quality System (MQS) is not an effort to cut people or costs (though costs often do decrease as a result of process improvements), or to make people work harder. Rather, it is an effort to make workflow smoother, more productive, more valuable to the customer, and easier for the worker. The philosophy is a natural extension of our goal of "Putting Patients and Families First."

Background about "Lean Thinking"

The term "Lean Thinking" was first applied to describe the Toyota Production System of product development, production, supplier management, customer support and planning, according to Womack and Jones, in the book, (Lean Thinking). In industry, this approach uses fewer "inputs" -- such as time, human effort and materials -- than traditional manufacturing to produce a wider variety of products with fewer defects more quickly. The Toyota Way has been applied successfully to a variety of industries, to companies that provide services to people, and increasingly to health care delivery.

Michigan Medicine leadership has committed to helping us all make this transforming journey, to create a new system for continuously improving all we do. We have named this journey the Michigan Quality System (MQS). We selected this approach for several reasons. We believe together we can create the Michigan Quality System (MQS) that builds on the learnings at Toyota and GM – a system that:

  • Creates the most value while consuming the fewest resources
  • Helps us see the root causes of waste and errors
  • Helps us solve the root causes, to transform waste into value from the perspectives of our patients, our co-workers, our payers and the communities we serve
  • Helps every worker at Michigan Medicine, clinician and non-clinician alike, continuously search for ways to make our work easier, safer, faster, and with fewer errors
  • Helps us do this every day

Eight Forms of Waste in Health Care

  • Overproduction and Production of Unwanted Products:
    • The most important form of waste – leads to all the others
    • Any health care service that does not add value to the patient
    • Antibiotics for respiratory infections
    • CT screening for coronary disease
    • Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use
    • Appropriateness – the key dimension of QI in health!
  • Material Movement:
    • Moving patients, meds, specimens, samples, equipment
  • Worker Motion:
    • Searching for patients, meds, charts, supplies, paperwork
    • Long clinic halls
    • No printer in exam room for prescriptions, patient education
  • Waiting:
    • ER staff waiting for admission, can’t see next patient
    • Waiting for test results, records, information
    • Nurse waits for blood draw, transport, OR cleaning
  • Over-processing:
    • Bed moves, retesting, repetitive paperwork, multiple consent forms, logging requests
  • Inventory:
    • Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis
    • Patient waiting for anything – tests, visits, discharge, phone cues
  • Correction of defects:
    • Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills

Adapted From Long: Seven Wastes of Healthcare, Mersereau, and Billi

Waste Category
Health Care Examples
Rework because of defects, low quality, errors.
Requisition form incomplete/inaccurate/illegible.
Order entry error.
Producing more, sooner, or faster than required by the next process.
Inappropriate production.
Unused printed results/reports.
Unnecessary labs/visit.
Motion Unnecessary staff movement (travel, searching, walking).
Walking to and from copier/office/ exam room.
Searching for misplaced form/ equipment/chart.
Material Movement Unnecessary patient or material movement.
Multiple patient/paperwork transfers.
Temporary locations for supplies.
Waiting People, machine, and information idle time.
Patient in waiting room.
Wait for lab results.
Inventory Information, material, or patient in queue or stock.
Patient waiting in exam room.
Excess stored supplies. 
Processing Redundant or unnecessary processing.
Reentry of patient demographics.
Repeat collection of data.
Underutilization Underutilized abilities of people.
Nurses refilling Rx or making appointments.
Doctors doing simple patient education.

What is a "Value Stream?"

A value stream involves all of the steps, both those that add value and those that don't, that are required to complete a service from beginning to end. It is, in short, "everything that happens to get the job done."

Value Stream Mapping

Value stream mapping is a paper and pencil tool we will use in the Michigan Quality System. It is a diagram of the process that occurs when a task is undertaken -- for instance; the steps needed to schedule a clinic appointment. The specific steps are "mapped" on paper, including the employees involved, the interruptions that occur in the process (time waiting for a scheduler to respond to the request), the error rate (the percentage of time the first selected appointment time doesn't meet the needs of the patient), and other details. Mapping the process on paper:

  • Makes work visible
  • Helps us understand workflow
  • Assists in measuring how well the process works in terms of cost
  • Will help us redesign the process to meet specific business objectives
  • Will allow us to use Lean tools to achieve the redesigned process
Value stream maps are created by the very employees who are responsible for performing the work involved. All of the people who are involved in completing a task are brought together in a group, where they together map out the various steps that take place to finish the task. They create a Current State Value Stream Map, a visual display of the way the work is done now.

Drawing a Value Stream Map to Achieve Future State Goals

Once the process has been mapped, the group can begin to analyze it, addressing such questions as:

  • Is process time too long? Process time is the time actually spent working on a task.
  • Can it be reduced? If so, by how much. How would you draw your map to meet this process time goal?
  • Is wait-time too long? Wait time is the time spent by a patient, process or service with no action taking place.
  • Can it be reduced? If so, by how much? How would you draw your map to meet this wait-time goal?
  • Is lead-time (process plus wait-time) too long?
  • Can it be reduced? How would you redraw your map to reduce lead-time?
  • Is overall quality (% complete and accurate) acceptable? Is there too much rework?
  • Can quality be improved and rework reduced? If so, by how much? How would you draw your map to meet this future state goal?

Source: Adapted from John Long, M.D., Lean Concepts, LLC

Future State Design Questions

Once the current state is mapped and analyzed, the group works to develop an ideal future state -- in other words, what the process should look like to meet the customer's needs. To design this improved "future state," again, questions need to be addressed, including:

  • What are our customer requirements? 
  • Where and how will you trigger or sequence work?
  • How will you establish rhythm or milestones to pace the work?
  • How will you make work flow smoothly? 
  • How will you make work progress, delays, and problems visible?
  • What process improvements are necessary?

Source: John Long, M.D., Lean Concepts, LLC

With these answers in hand, an improved, simplified and efficient process can be developed and implemented. Once implemented, the work continues as the new process is monitored and improved.


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