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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

A Sheridan Healthcare WHITE PAPER

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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.


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?

?


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.


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.


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.


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.


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].

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Lean Process Improvement - Sheridan Healthcaresheridanhealthcare.com/.../content/Sheridan_White_Paper_Kaizenology… · SHCRCOM Lean Process Improvement How to Do the Impossible with