In this post, I'd like to share a nice 7-minute video from St. Clair Hospital in Pittsburgh, showing the transition from an inefficient “par level” system (that often led to stock outs for nursing supplies) to a two-bin kanban system that works. The video was produced by St. Clair, not by me. I appreciate them sharing the video with the world.
The video shows the process they went through, including comments from the industrial engineer, who was hired to put the system in place. With the system in place, they had ZERO stock outs and zero manual requisitions sent down to materials management.
The video also has some interesting comments from a manager who was initially VERY opposed to the kanban system… but is now a fan of the system.
When I tweeted the video last week, there was a comment back about how the items in the kanban system were clearly non-charge items. One hospital (it was either Seattle Children's or Park Nicollet… or both, I forget) told me once when I visited that, when they put a kanban system in place, they took out MOST (not all) of their automated inventory control cabinets. Many of the items they thought were charged to patients were actually not charged… so they didn't need a cabinet to track usage to patients – they just needed a system that ensured staff have what they need for the patients. And, kanban does just that.
There's certainly time and effort required to put a system like this in place… but it just works. The investment in system design pays off in terms of better staff satisfaction, reduced waste, and better patient care.
The video:
At 1:44 in the video, you'll actually see a picture of a kanban card from the Lean Enterprise Institute office (used to replenish coffee pods), that I featured in this blog post from 2010. See how LEI helps the Lean community? :-)
The video also makes think of the comment people often make: “We can't turn the hospital into some sort of factory.” Well, factories generally do a better job of making sure their front-line staff have the supplies and materials they need – right at the point of use. Using methods from factories, like 2-bin kanban systems, allows healthcare staff and clinicians to be less rushed, more caring, and better providers.
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Very good video with some great customer comments. I especially like the resistance comments and changed to support as the project progressed.
Very generous of St. Clair Hospital to share this video. Tania Lyon had such trouble getting information in the beginning that she created the video to help others get started.
Also, notice that fixed cabinetry is the Enemy of Lean! We saw this time and time again when I was writing Lean-Led Hospital Design (www.leanledhospitaldesign.com). Standardizing storage rooms is as important as standardizing patient rooms. And creating flexible space (e.g., nothing attached) makes continuous improvement possible. The video hit a lot of notes. Thanks for posting, Mark.
Thanks for posting this video. It was so helpful to see the demonstration on how they made the change and hear the staff’s experience. Also, including the before and after of the manual requests demonstrated how immediate the impact was.
We overhauled our supply system at Covenant in Lubbock, TX a few years ago with many of the same successes and barriers you mention. We, however, went with the wall hung bins instead of placing on metro carts as in video. They consume much less space but may limit us on how we use the 2 bin system. Has anyone used a bin within a bin with any success? Still same concept but might work with wall hung bins.
Let me know your thoughts….brad.
What do you mean by “bin within a bin,” Brad?
I like the carts because that 2nd bin can be placed behind the 1st, or stacked underneath.
Hi Brad
The wall-hung bins are efficient in space usage (with no space wasted behind the bins), but the metro carts offer tighter first-in-first-out control as it offers only one picking face per SKU. The FIFO benefits are very important to system reliability and stability. It prevents picking from both bins at the same time, giving two empty bins.
So I would say go with carts and select bin sizes to efficiently use space. The industrial engineer (apologies for dropping the name as he did great work) emphasised the time taken to determine quantities and bin sizes. It is an important point.
“Bin-Within-Bin” tends to lose on FIFO control and visual simplicity.
Hope that helps.
[…] Here’s a great video from a Pennsylvania hospital about converting from a par system to kanban, a different pull system that’s less labor intensive. […]
Has anyone posted the reduced steps to the Materials Management team? Reduced steps to Central Supply Staff? Nursing? how many delays were eliminated to the patients and how has this impacted outcomes? Any consideration with charges that should be considered.
we are considering implementing a similar system but need to convince those that like the existing system… metrics speak.
thanks
Davidd
I think the best way to convince people is to do a pilot in one department and see what your results are.
There might possibly be MORE walking for materials management, but the real goal is reducing nursing time/walking and making sure they have what they need for patients.
I know hospitals have found a big gap between what’s “chargeable” and what’s really being charged. Some items might need to be kept in the automated inventory cabinets for the sake of charging (but then you’re still relying on staff to properly press the buttons).
This is a pretty basic system that works but you will still have to have a huge amount of inventory on hand. This will not cut down your inventory costs whereas if the system manages your par levels you can theoretically cut your inventory in half (reality at least 25% to keep nervous managers happy, they like a reserve in place but that is not necessary).
Nicolos – I don’t understand what you are saying.
The math to set up the inventory level max is exactly the same with kanban as it is with a par level system.
The problem is a par level system requires a lot of counting, whereas a two-bin kanban system allows easier and quicker restocking.
“Nervous managers” is a problem whether it’s kanban or par level.
Mark
What about long items? Those bins appear short, and it looks like it would work for for the items that fit. I like the concept, but those wire racks look like they’re at least 24″ deep, this takes up a good deal of floor space.
Maybe go with a shelf bin (24″ deep) and set your pars at 10 days and refill at 60% of par. Just have staff scan the items that are running low.
Our hospital has supply Pyxis for chargeable and ParAssist wall bins for the grab and go stuff (non-charge). We have have 96% + compliancy for the Pyxis charge stations. The Par bins (N/C) are less urgent-type items. Staff seems to like it.
Great questions and I see no one responded. They have to be 24″ in order to get those bins doubled up. The bins are about 12″ deep it they are the Akro 235 size bins or similar. I love the work done but we scan supplies from the unit using optiflex. We have to stay with the par level process but wonder how we can implement the kanban idea as well. I would love suggestions. Thanks for the post.
Why do you “have” to stay with your par level process? Kanban works better.
[…] Video on a “2-Bin” Kanban System at a Pennsylvania Hospital (2,851) […]
The 7-minute video from St. Clair Hospital in Pittsburgh is no longer on this link. Is there a way for you to email me the video or share a different location? We find this video useful in educating our staff on what Kanban is. Thank you.
Hi Jean – The YouTube video still works for me. Is your organization blocking access to YouTube?
Mark,
Nice Video. so if i was a hospital looking at vendors to buy 2 bin kanban systems from, whats the best way that makes sense economically to pay for this? should we go with subscription model where we pay yearly fee, should we pay by SKU#’s being handled, should we pay by room.
Different vendors have differnt pricing models, so its really confusing on how to pay for this, i am not talking about the HW i am talking more about the SW with smarts and the service fees. Any suggestions of what pricing model makes sense so i can justify investment?
-Tapan
Hi Tapan –
I think you’re asking good questions, but I don’t have enough information here to give you an informed answer…
Good luck with your evaluation of these approaches and thanks for reading.
Mark
Great example of using a low cost system with little technology required to bring efficiencies to the organization.
Key takeaways:
1. coming in under budget each month (better cost management)
2. no complaints
3. no shortages
How about that!
Hi
We have installed a kanban 2 bin system in our hospital. One major problem, The Nurses are not turning the cards to red. The ward managers are telling the Healthcare assistants its there job not the nursing staff!!!!!.
So everywhere morning (we do daily top ups) we are met with bank of red cards because the staff feel they need stock, not because the first bin is empty.
so over the first year stock takes are greatly reduced but the saving across the kanbanned wards are minimal..
Please help, how can we explain the ward managers and nursing staff,
Hi Simon-
It sounds like there are many problems here. For one, if you do “daily top ups,” that’s not a kanban system.
I wonder if the nurses were involved in the process of designing the kanban system? Do they really understand how it works?
If the nurses are using the cards inappropriately, are they getting coached on that? The ward managers should encourage the nurses to turn in the cards when it’s the right time, as that shouldn’t take very long at all.
There’s no easy answer to that other than maybe finding somebody who can help you on site, somebody who is experienced with kanban and somebody who can coach your leaders. I wouldn’t blame the staff… I’d blame leadership here.
Good luck,
Mark
Hi Mark
We are doing daily top ups… Because when we first started our 2 bin system… Because the Cards were not been turned by ward staff.. We was getting lot of Stock outs…. So we reduced the Stock to 4 days in the Bins….. This way we visit the Wards every morning Mon to Fri….. and on average we replenish 5-10 bins (out of 190) per day…. The savings are around 40%…. Much better then when we was doing it weekly (replenishing 100 out 0f 190 bin)s…… But still the problem is ward staff ;-)…..
Maybe the ward staff need to realize — if you don’t turn in the cards or bins, then you don’t get new supplies.
I’d still consider it a process problem, not a people problem. Why aren’t the staff turning in the cards?
According to the Ward managers. Nurses are too busy!!!!
From a distance, that seems like a lame excuse. Do the nurses have the time to deal with the problems caused by NOT having supplies on hand?
Is the Kanban system as easy to use as it can be? Meaning… do the nurses not have to walk anywhere to turn in the cards or empty bins? This has to be made as easy as possible.
When somebody says “I don’t have time,” we should ask “why don’t you have time?” and “what can we do to make this work?” rather than letting “lack of time” be an excuse.
See this post that’s linked to below:
Excellent work to promote 2-bin kanban for healthcare supplies. There are systems that offer more flexible storage than bins and can still do kanban. Best of both worlds!
Glenn Tamir
Pegasus Medical Concepts
I have a few questions as I look towards implementing 2-bin and then moving on the E-Kanban as we upgrade our RFID infrastcuture:
1- What formula is used to determine how much goes in each bin? I see that you stated you use the normal PAR formula, but I have seen different formulas for 2-bin. If your PAR formula is working, it would be good to have that
2. How did you deal with nurses who have height limitations? :)
3. Do you think an engineer is always required?
Thanks for your questions, Tony.
In no particular order:
2) Easy answer: You might sure that supplies aren’t stacked too high (or too low) taking ergonomics of your staff into account.
3) No, but somebody who has experience with kanban systems would probably be useful at some point, if that’s what you meant the role of an “engineer” to be
1) Many organizations already have a Par level formula or calculation. It’s basically the same as the logic I go through:
— What’s the typical replenishment time for getting more supply? This includes the frequency at which bins are checked and how long it takes to get more stock.
If there’s a daily bin check and empty bins are restocked the next day… call that a 2 day replenishment time. If bins are checked daily and delivered an hour later, call that 1+ days.
You then need to think about the “practical worst case” usage quantity over that replenishment time. What’s the most you could expect to use in X days? You have to take variation into account… but you can’t protect against the absolute worst case scenario probably.
If you expect to use 10 items per day and the replenishment time is a day… and the expected most you’d use in a day is 15, I’d set up 2 bins of 15. Or maybe you’d start with 2 bins of 20 and make sure that you’re not running out before the 2nd bin arrives. You can tweak the bin sizes down a bit over time (or adjust them for seasonality).
It’s more of a thought process than a formula. I hope that helps.
standard deviation doesn’t seem to be used as much in the places I have visited, hence my confusion as to using the PAR that pops out of the system. Our goal is to decrease inventory in the areas by making more runs per day instead of just 1 per day. In my opinion this is key to clinicians trusting you as you visit them 2-3 times daily, while at the same time keeping stock to a safety minimum. thanks for your help
Even if you don’t have exact data to calculate a standard deviation, you can estimate a safety stock or fudge factor. I’d say, at first, it’s better to have a little too much inventory than too little and drain down the safety stock if experience shows you have too much.
For example, if you have two bins of 10 and there’s usually 7 items left in the 2nd bin when the replacement comes, you might have too much safety stock and you can maybe go to 2 bins of 8.
The main goal should be supply availability, not keeping stock to a minimum.
You’re right that delivering more frequently means lower inventory levels. But you have to look at the tradeoffs of labor cost for those trips.
correct about the labor side, which is difficult to calculate until you run out of something :) I will keep you posted on our trial in Anesthesia to see how it goes. Our goal is to use RFID in the future- we have a meeting with Aerscout to understand their capabilities of mobile equipment and for tagging bins that trigger an emptye bin when moved
I mean the labor time for materials… that’s easy to measure/calcuate.