lean process improvement - Sheridan Healthcare process improvement ... Kaizen A lean methodology, rigorous discipline, and open ethic of continuous improvement that enables people to achieve worthwhile

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

    sHeridan leadersHip brief

    neOnatOLOGYanesthesiOLOGY emerGencY radiOLOGY

  • 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 isnt

    realistic. Often, the believability of an event is dependent upon an individuals 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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    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, lets 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.


    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 patients 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 hospitals

    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?

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    staff enjoyment in

    coming to work

    Having every person do every

    thing right

    long-term process


    better quality & faster service

    at lower cost

    driving out fear & predicting

    the futuresustained


    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.

    leadersHip drives perfOrMance page 4

    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


    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 nurses 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.

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    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.

    leadersHip drives perfOrMance page 6

    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 protocols 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.

    855 .252 .2969 | sher idanhealthcare .com

    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 Childrens 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.

    leadersHip drives perfOrMance page 8

    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 whats 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, its 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 leaders anxiety when making

    decisions to forward a hospitals 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 problemsan option, before

    Kaizen, that truly once seemed impossible.

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