Issue 12 – Oct 2012


Issue 12 • Oct 2012

Implementing Pull

by Steve Newlon

A lean system desires that work flow nonstop through the entire value stream (VS).  In every VS, constant flow from one value-added step to the next typically doesn't exist.  This means a hand-off from station to station occurs.  Pull first directs us to examine this handoff.  Establishing a clear method for handing off from one process to the next is called "creating a tight connection."  Defining the alert to tell the supplying process to start or to deliver is called "trigger."  A trigger is like a starter's pistol signaling runners to start.  Even with a tight connection and a trigger, we still don't necessarily have pull.  A key component of pull is that the sending process stops producing and waits if a trigger isn't received.

In healthcare, many times a hospital department will process a patient and send them down to the next department where they wait.  When someone gets or "pulls" the patient from the waiting room, this is often, and incorrectly called pull.  True pull is present if the sending department actually stops processing patients when the receiving department "stops pulling".

One hospital spent months trying to connect their Post Acute Care Unit (PACU), post surgery, to the nursing division.  They had implemented  phone calls, standard work and many other things with little progress.  When the patient was ready to move, the PACU began their push to the nursing division.

More recently team members agreed to implement a pull system.  This means that even if a patient is ready to move, PACU holds the patient until nursing pulls them.  This could mean PACU holding patients longer and the number of patients in PACU growing and if all spaces were filled, surgery would have to stop.

Since stopping surgery is a major issue, the hospital is putting in safe guards, but is closely guarding against the PACU being able to call or push patients to the nursing division.  One safe guard will be an andon signal for PACU to pull if the number of patients starts getting dangerously close to capacity.

Standard work defines the response to this andon signal which involves management's intervention.  Lean tools are used to make this pull system work.  Tools include visual boards in nursing to know if a bed is available. A checklist to complete when a problem occurs.  An andon light to alert key people of a potential problem and standard work for staff to use. People foresee the problems that will surface if a pull system is implemented and use these reasons to argue against it.  A pull system reduces WIP inventory and in reducing inventory it lowers the water level allowing existing problems to come to the surface.  This surfacing of issues and the need to urgently resolve them is another purpose of a pull system.  It may be counterintuitive to try a pull system, but the results are amazing.  Flow increases and process noise reduced.

Principles of Lean Improvement

Today we will focus on understanding the five principles of lean improvement. This article begins with the premise that the reader has an understanding of the 7 wastes plus the waste of un-evenness and the waste of over-burden. Improvement at its most fundamental is about seeing and eliminating waste. The ability to identify waste is the first hurdle in any lean improvement.
Eliminating waste is the next step, and usually a bit harder than seeing it. To eliminate waste using lean thinking, we apply the principles of improvement. The five principles of lean include the following:

  1. Create Flow
  2. Implement Pull Systems
  3. Zero Defects
  4. Manage Visually
  5. Practice Kaizen

Using these five principles repeatedly will eliminate large chunks of wasted time and activity. Each time wasted time and activity are reduced, the entire system "improves". In a continuously improving system, everyone works to produce the highest quality, in the shortest lead-time at the lowest cost.

Let's map the improvement principles to elimination of the common wastes:


The good news is that the common forms of waste are eliminated when the principles are correctly applied. The pull article on page one is a deeper dive into the principle of pull. We'll cover the other principles in upcoming issues.

In The News

Sample comments from the Oct 17/18 Lean Facilitator's workshop participants:

" I just wanted to let you know how much I enjoyed the workshop last week. It was most informative and my brain has been LEANing ever since."

" I can’t say enough about the course, I left very “pumped” at the same time, realistic. I need some time to digest and take each piece at a time with our team and resources to work through and put the these tools in the right place."

The next public workshop will be the Shingo Prize Lean Bronze Certification. Likely this workshop will be held in the Greater Toronto Area in February or March of 2013. Stay tuned to the next Breakthrough Highlight newsletter.

The book, “Taking Improvement from the Assembly Line to Healthcare”, has been awarded The Shingo Research and Professional Publication Award per the recommendation of The Shingo Board of Examiners.

Shingo Book Cover.jpg

Ron Bercaw joined a distinguished group of recipients who have demonstrated a commitment to promoting Operational Excellence through published works and we are proud to add you to that elite group.

-The Shingo Prize

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