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lean process improvementHow to Do the Impossible with Physician-Led Teams

sHeridan leadersHip brief

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tO perfOrM best in cHallenging circuMstances, a leader Must

redefine what “impossible” means. The word connotes that something cannot be

done simply because it seems utterly impractical, existing outside of any degree

of reason. When so many intricate factors govern the success of the whole, many

hospital goals do appear to be impossible.

Consider the inner workings of a hospital to be a kind of complex magic show.

Here, the notion of impossibility is surely a subjective measure as to what is or isn’t

realistic. Often, the believability of an event is dependent upon an individual’s point

of reference, long-held beliefs, and involvement in the process. And unless one

understands how each intricate step functions to create the whole, the audience is

left with only the impression of “impossibility.”

introduction


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KaizenA lean methodology, rigorous discipline, and open ethic of continuous improvement that enables people to achieve worthwhile changes to a system or process while at the same time decreasing chaos and confusion.

leadersHip drives perfOrMance • page 2

doing the impossibleacHieving tangible prOcess iMprOveMent in tHe clinical setting is neither magical nor impossible. The use of Kaizen,

in particular, is a short-term intense action that makes processes

more reliable and less wasteful while encouraging legitimate and

meaningful employee involvement.1 During Kaizen, understanding

the flow of information and people allows the “impossible” to

become surprisingly apparent.

Knowing this, let’s dive deeper into the idea of transforming the

“impossible” into realistic solutions. For example, a radiology

special procedures room needed to speed up the change-over

process before the next procedure, yet everyone seemed extremely

busy, giving off the impression that each person was going as

quickly as possible to achieve the best results. The hospital nurses,

who insisted that improvement was impossible, only saw the rushed

chaos when making their assessment – how much faster could

everyone really move to achieve better performance?

Since the busy change-over provided the illusion of productivity, an

observer had to look at the interactions among each individual part

to analyze how it flowed to find the challenges to the process.

The initial steps of this Kaizen discovered these silent threats,

so addressing them became the next stage in locating realistic

ways to speed up the process. To get the radiology room

performing at its best, the leaders (physician, nurses, and tech

staff) charted the process in its entirety with the help of a time

study, spaghetti chart, and other Kaizen tools. By the end, the

leaders were able to minimize the 30+ minute process to 22

minutes, while also removing the need for an additional nurse –

saving time, resources, and costs.

challenges

The list of challenges, any of which would suggest a wasteful use of time, space or resources, included items such as these:

• No standardized procedures were in place that informed staff how long it took to get a room ready for the next case.

• Supplies were not in the right place at the right time, causing people to move to the other side of the room and leave the room multiple times.

• Wiring on the floor consistently tripped people and limited the patient’s own mobility, and the entryway required the effort of two nurses to bring the patient into the room.

What this anecdote hopes to demonstrate

is that, like a magic show, a hospital’s

“impossibilities” can be an illusion.

While hospital leaders are bombarded

by people who all seem to have

“the solution” to one problem or

another in the clinical setting,

each of these offered solutions

only muddles the process of

finding the best answer. Kaizen,

however, gets the best out of

everyone, allowing clinical leaders

to do the “impossible” with

proven industrial tools.

assessing the clinical settingin assessing tHe clinical setting, prOgress is Made by Having tHe HOspital staff identify the biggest time wasters and processes that lead to inefficiencies. These processes can be examined

and new procedures can be tested. Before attempting to make changes, however, a Kaizen requires a

strategy and a clear vision, so answering some fundamental questions about the nature of the organization

can help a Kaizen team locate its mission.

Fundamental questions:

• What is the purpose of the organization?

• What is the value proposition of the company?

• Why does it exist?

• By what means and principles will the vision be obtained?

• How is success toward that purpose measured?


staff enjoyment in

coming to work

Having every person do every

thing right

long-term process

improvement

better quality & faster service

at lower cost

driving out fear & predicting

the futuresustained

buy-in

the impossibles that kaizen

makes possible

?? ?

three perspectives: Time, Space & Concurrent SequencetO get a clearer picture Of wHat is Occuring in a given prOcess Or systeM, tHe tHree perspectives of time, space and concurrent sequence should be analyzed to spotlight improvement opportunities.

Here, multiple perspectives help to paint visible pictures to “impossible” problems.

While observing the department in motion, address the following questions:

• How long does it take?

• What kinds of defects or errors might occur at this step in the process?

• What do you have to do to get ready to do the next case?

• How many can be done in a day?

• What triggers the work?

• What preventative actions or rework occurs to handle defects?

value stream MappingOne tOOl fOr Observing current prOcesses relies On value stream mapping (VSM). VSM shows how materials, people, equipment,

methodolgy, and measures interact over time to create value for the customer.

VSM illuminates the flow of physical events while keeping disruption and

confusion to a minimum. Although VSM may end up looking like a convoluted

mess to the untrained eye, the map is a very powerful way to identify problems

and constraints for Kaizen topic selection. Since the map has the potential to be

over-drawn, remember that the intent of the map is to enable people to see how

time and resources are lost along the path of the work flow. This map allows

techs, RNs, physicians, or surgeons the ability to become engineers, seeking to

drastically reduce time, complexity, and errors in each step of a clinical process.


To stimulate ideas for improvement, an experienced team will carefully watch the process to see when the operator:

• Adds value

• Does necessary but not value-adding work

• Checks information

• Walks carrying something

• Walks empty-handed

• Does rework

• Waits

• Watches a machine run

value stream Mapping

Next, a “spaghetti chart” shows how and when things occur over a given space by tracing the steps of the

operator on the standard work form, or graph paper.

During a Kaizen event, a spaghetti chart showed the distance traveled by a variety of people involved in

one interventional radiology case showcasing how location affected the process in terms of efficiency. After

analyzing multiple walking paths of the patient, doctor, nurse, and technician, the goal is to make the highest

volume of work have the least movement to help save time and improve quality of service without adding cost.

As another example, even one nurse’s movement during pre-admission testing can be altered to improve work

efficiency. By remaining in the same general location per case, the nurse gains better turnover time and speed,

in turn saving money by doing more work in fewer minutes. Attaining better quality and faster times with less

cost is noted as an “impossibility,” yet a spaghetti chart can reveal solutions for increasing productivity.


value stream Mapping

spaghetti chart

concurrent OperationstHe standard wOrK cOMbinatiOn sHeet illustrates sequential and cOncurrent OperatiOns over time while highlighting gaps. When looking at this sheet, one can pinpoint what to try to change by locating

the longest bar and asking if anything can be done concurrently or if the event can be shortened in any way.

Standard Work Combination Sheet:

As all these charts demonstrate, the perspectives of time, space, and concurrent sequence play a vital role

in documenting the changes from prior practices to the improved future state. In this way, Kaizen forces an

organization to gain a better understanding of the “impossible” within the current state and locate the best place to

move toward the true improvement of service.


simultaneous rather than sequential work pattern

the value of physician-led teamsin respOnse tO HealtHcare refOrM, HOspital leaders have been trying to reduce costs while maintaining quality patient

care. However, knowing only the basics of Kaizen can bring a

hospital more harm than good. To attain true Lean transformation,

the type thriving in both industrial and clinical settings, Kaizen

needs to be done as a long-term project with the help of an expert

Kaizen facilitator and the support of the entire medical staff.

One mistake in the broader clinical community is that anything done to cut costs may be considered “Lean,”

including staff elimination. True Lean methodology, however, focuses on continuous improvement and the

genuine respect for each worker – not their elimination. Here, respect means wanting to see everyone excel,

increasing staff morale through cross-level buy-in.

Kaizen promotes using the creative minds of people at all levels of the organization, so one person or one job type

cannot represent the “hero” of the group. Still, in the clinical setting, special attention should focus on physician

involvement – a key factor that influences a protocol’s clinical acceptance and long-term sustainability.

A clinical Kaizen team consists of a variety of hospital staff, but

without physician buy-in, many Kaizen teams find that their process

improvement goals get blocked by physicians who are unwilling to

change. While physicians’ participation hinges on many factors,

studies suggest that physicians are reluctant to participate in process

improvement projects due to fear of hospital motives and lack of time,

and these barriers impede the success of process improvement

efforts.2 To counter such reluctance, executive leadership should enact

company-wide initiatives for process improvement based on successful

Lean principles used in other industries.


Kaizen has taken us to a different level both in implementation of new workflow as well as recognition of the division and the company in our facilities. It allows for a relaxed and productive forum in which to problem solve in the clinical setting. This is unique and enjoyable in an environment that is usually stressful and demanding.

— Maria Rodriguez, MD CMO of Radiology

I am truly impressed by such a thought-provoking and amazing experience. I will certainly recommend Kaizen to others.

— Richard Auerbach, MD, SVP Children’s Services Division

We had tons of good feedback and comments from our Kaizen in Emergency Medicine. We were thrilled it went so well. It was great to have all departments involved.

— Annette Small, Hospital CEO

When hospitals have access to extensive in-house

process improvement resources, including the expertise

of senior leadership and transitional leaders in operations

and management, they gain a stronger culture of “Lean

Thinking.” Whether trying to combat low case volume,

high wait times or poor staff satisfaction, physicians who

establish quality as priority and who work in a quality-

focused culture have the greatest ability to organize

the resources necessary to support ongoing Lean

transformation. Only then can hospitals significantly

differentiate themselves from their competition as they

strive to continually optimize efficiency and the

utilization of resources.

Measuring Outcomes & resultscase studies Outline HOw Kaizen functiOns in tHe clinical setting. tO delineate a clear before and after, a Kaizen case study includes the following sections to properly measure outcomes and results:

bacKgrOund: Information about the facility pre-Kaizen, including problems in the specific department and concerns of the staff.

preparatiOn: The factors that led up to the Kaizen and the people selected to be on the Kaizen team.

event: Observations during the Kaizen are documented and traced; facts are validated; processes that occurred during the event are noted.

results: The comparison of the problem, pre-Kaizen and post-Kaizen, in terms of time, space, or other factors.


Some Kaizens, like some patients, are tough cases, and they come back. The first therapy or treatment may not always be the right one. Sometimes you have to throw out what you thought was the right solution and try again. We experiment and try different solutions, various rehab and therapies. We understand that we have to continue to monitor and continue to strive to do what’s best. One of the great similarities is that passionate people are involved, who all are there to come up with the best solution for the patient, and we saw that it could be collaborative, even with passionately different opinions.”

— Andrew Greenfield, MD, EVP of Anesthesia

saMple Of Kaizen results:

Overcoming fear of changeeven tHOugH tHis paper fOcuses On Kaizen in tHe clinical setting, it’s gOOd tO remember Lean thinking from its start at Toyota in the 1930s. At Toyota, their continual small improvements

(Kaizen) added up to major benefits: faster delivery, lower costs, and greater customer satisfaction.3

Today, as noted in the Harvard Business Review, all levels of hospital staff are “radically increasing

the effectiveness of patient care and dramatically lowering its cost by applying the same capabilities in

operations design and improvement that drive the famous Toyota Production System.”4

Through Kaizen, “impossible” problems become visible, thereby reducing a leader’s anxiety when making

decisions to forward a hospital’s growth and success. When hospital leaders have access to in-house

process improvement resources, they no longer need to seek out multiple, outside consultations because

leaders finally have the tools at hand to generate novel solutions to dynamic problems–an option, before

Kaizen, that truly once seemed impossible.


100% trACkiNg OF ChArt Delivery time tO SAme DAy Surgery

88% reDuCtiON iN leFt beFOre beiNg SeeN (lbbS)

73% reDuCtiON OF SAme DAy CASe CANCellAtiONS

37% grOWth iN ServiCe vOlume WithiN 2 yeArS

20% reDuCtiON iN imAgiNg CyCle time FOr StrOke Alert iN the eD

references:

1. Cooper, M. (2008). Kaizen sketchbook: A comprehensive illustrated field guide for lean transformation. Lake Forest, IL: Moffitt Associates, LLC.

2. Weiner, B., Shortell, S., Alexander, J. (1997). Promoting clinical involvement in the hospital quality improvement efforts: The effects of top management, board, and physician leadership. Health Services Research. Retrieved from http://findarticles.com/p/articles/mi_m4149/is_n4_v32/ai_20123544/

3. Kaizen History. QualitiAmo. Retrieved from http://qualitiamo.com/en/improving/kaizen/history.html

4. Spear, S. (2005). Fixing health care from the inside, today [Abstract]. Harvard Business Review, 83(9), 78-91.

nOtes:


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about sheridan HealthcaresHeridan is One Of tHe leading prOviders Of HealtHcare sOlutiOns fOr anestHesiOlOgy and OtHer specialties to physicians, hospitals and outpatient centers. Physician led and managed, Sheridan provides comprehensive clinical and management solutions for anesthesia outsourcing and other specialty areas including emergency medicine, neonatology and radiology. Our dedication to collaboration, leadership and quality provides our hospitals and patients with the care they deserve.


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