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Lean Process ImprovementHow to Do the Impossible with Physician-Led Teams
Authorized by:Darlicia Alexander, MD
Anthony Andrulonis, MD, FACEP Richard Auerbach, MD
Roger Brown, MDManuel Casanova, MD
Gilbert Drozdow, M.D., MBALee Fox, MD
Luiz Grajwer, MDAndrew Greenfield, MD
Andrew Guttman, MDCourtney Harris, MD
Glenn Kaplan, MDGerald Kranis, MD
Lester McIntyre, MDHoward Peters, MD
Maria Rodriguez, MDMatteo Rosselli, DO
Bruce Schulman, MDArt Smith, MD
Written by: MaryPat CooperAmichay Porges
with Jennifer Farmer 2012
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KAIZEN
A 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
Introduction
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 times, 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.”
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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.i During Kaizen, understanding the flow
of information and people allows the “impossible” to
become possible – and 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 time results. The hospital
nurses, who insisted that improvement was impossible,
only saw the bigger picture when making their assessment
– how much faster could everyone really move to achieve
better performance?
Since the bigger picture provided the illusion of
productivity, an observer had to look at the interactions
among each individual part to analyze how it flowed in
order to find the challenges to the process.
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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.
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Staff enjoymentin coming to work
Sustainedbuy-in
Long-term process
improvement
Having every person
do every thing right Driving out
fear and predicting the future
Better quality and
faster service at lower cost
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 their over 30 minute process to 22 minutes,
while also removing the need for an additional nurse –
saving time, resources, and costs.
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.
THE “IMPOSSIBLE”
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What is the purpose of the organization?
By what means and principles
will the vision be obtained?
What is the value proposition
of the company?
How is success
toward that purpose
measured?
Why does it exist?
?
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Assessing the Clinical Setting
In 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.
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Three Perspectives:Time, Space, and Concurrent Sequence
To get a clearer picture of what is occurring 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.
One tool for the observation of the current process
relies on value stream mapping (VSM). VSM shows
how materials, people, equipment, methodology,
and measures interact over time to create value
for the customer.
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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?
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Value Stream Mapping
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.
As seen below, 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.
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.
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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
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The picture to the right shows the distance traveled by
of a variety of people involved in one interventional
radiology case, showcasing how location affects 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, the “Before and After” charts (to
the right) showcase how 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 one of the “impossibilities,” yet this hand-
drawn spaghetti chart reveals solutions for increasing
productivity.
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Concurrent Operations
The 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. Additionally, this
particular sheet was filled out by a physician on the Kaizen
team, proving that Kaizen tools are accessible to people
outside of Lean expertise.
STANDARD WORK COMBINATION SHEET 4/29/2011
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As these three charts demonstrate, the perspectives of
time, space, and concurrent sequence play a vital role
in documenting the changes between prior practices
and 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.
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The Value of Physician-Led Teams
In response to the weakened economy, hospital leadership
has 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.
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TRUE LEAN METHODOLOGY,
HOWEVER, FOCUSES ON CONTINUOUS
IMPROVEMENT AND THE GENUINE
RESPECT FOR EACH WORKER – NOT
THEIR ELIMINATION.
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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. However,
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.ii To counter such reluctance,
executive leadership should enact company-wide
initiatives for process improvement based on successful
Lean principles used in other industries.
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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 on-going
Lean transformation. Only then can hospitals significantly
differentiate themselves from their competition as they
strive to continually optimize efficiency and the utilization
of resources.
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Measuring Outcomesand Results
Case 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.
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Overcoming Fear of Change
Even 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.iii
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.” iv
Through Kaizen, “impossible” problems become visible,
reducing a leader’s anxiety when making decisions to forward
a hospital’s growth and success. With access to in-house
process improvement resources, hospital leaders 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.
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Summary
With access to their own process improvement resources,
hospital leaders are able to make important decisions that
foster growth and success faster and more easily. Through
Kaizen, daunting undertakings can be viewed in achievable
parts. Leaders see how each step in a given process
functions. They see the interaction between the parts and
identify challenges to the flow.
Kaizen tools combine multiple perspectives of time, space,
and concurrent sequence to help paint a clear picture of
what is occurring. Realistic solutions can be developed
with the help of meaningful employee involvement. True lean
transformation is a continuous project achievable
only with the full commitment of the entire medical staff.
And it is always worth the effort.
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References
i Cooper,M.(2008).Kaizensketchbook:Acomprehensiveillustratedfield guideforleantransformation.LakeForest,IL:MoffittAssociates, LLC.
ii 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/
iii Kaizen History. QualitiAmo. Retrieved from http://qualitiamo.com/en/improving/kaizen/history.html
iv Spear, S. (2005). Fixing health care from the inside, today [Abstract]. Harvard Business Review, 83(9), 78-91.
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About Sheridan HealthcareSheridan Healthcare, Inc. is a national hospital-based, multispecialty physician services company that provides anesthesia, radiology, emergency medicine, neonatology and other pediatric subspecialties. Sheridan, its subsidiaries and affiliates currently operate in 24 states and employ more than 2,200 providers. Sheridan’s anesthesia division, established in 1953, has become the leading anesthesia services provider in the country. In addition to physician and allied health services, Sheridan also provides support, training and management in non-clinical areas. Sheridan is recognized by the National Committee for Quality Assurance as a certified physician organization.
To find out how your hospital can benefit from Sheridan’s leadingphysician-run management expertise, e-mail us at [email protected].