Notes

Strengths and weaknesses

Strengths:

• Short study duration - Kaizen Events occur over periods of 3-7 days
• Implements real changes/improvements – the Kaizen Event takes process mapping and redesign to the next level by rapidly implementing the process revisions, which creates instant results (i.e. instant process time savings)
• High acceptance levels - because there are representatives from all participant groups in the Kaizen team, acceptance levels of the Kaizen solutions tend to be generally quite high (as the changes are made to suit everyone’s needs, not just the needs of some). It also helps to have a champion from each of the participant groups to help teach the process changes to the rest of his/her colleagues.
• Well rounded analysis - the Kaizen Event results are gathered through both collaborative discussion and empirical evidence

Weaknesses:

• High resource use - Kaizen Events require the full time participation of several staff members throughout the course of the event
• Short-term observational results can be misleading - only short periods of time are spent empirically observing the process workflow, which could lead to unrepresentative results
• The Hawthorne effect - it can be argued that the observation of subjects causes them to change their behaviour; thus, causing the observation results to be unrepresentative

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Plan

1st cycle

Plan 1st cycle

Form the Kaizen team

The first step in the Kaizen process is to form the multidisciplinary Kaizen team. The Kaizen team needs to have at least one expert in the Kaizen process improvement methodology (including one Kaizen leader, who will lead the team through the Lean processes), as well as several experts who understand the various aspects of the process under study. The process experts should be representatives from each of the process participant groups defined in the user profile sets (created in the previous phase of Rapid Response). Having a group of representative process participants of every type in the Kaizen team, enables the group to make rapid, well informed process refinement decisions that are agreeable to all parties involved with the process.

Plan the Kaizen meeting

Once the Kaizen team is formed, the Kaizen meeting can be planned. At least one week before the meeting, each member of the Kaizen team should be given some material explaining the Kaizen process, and what the goals are of the planned Kaizen Event. Also included in this material should be: the contact information of the Kaizen team members, instructional information on the Lean tools (i.e. Value Stream Mapping, 5 Whys, Spaghetti Diagramming, 5 S, etc.), and the planned meeting schedule (what the team should hope to achieve on each day).

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2nd cycle

Plan 2nd cycle

Develop an implementation plan for the revised workflow

The Kaizen Event is a methodology which not only utilizes rapid solution development, but rapid solution implementation as well. Using the future state VSM defined in the previous stage, the Kaizen team must develop an implementation plan to turn their solution into a reality. The implementation plan will need to answer questions such as:

• Who is responsible for doing what (define the resources)?
• What tasks need to be done, and what will be their outcome (define the work)?
• When will the tasks need to be done (define the schedule)?
• Why should each implementation task be performed (justify the work)?
• How is the work going to be done (plan the work)?

What makes the Kaizen Event implementation plan special is that it can be created in a very short period of time, since everyone that needs to be involved is already in the room and fully understands the situation. At the end of this planning stage, the Kaizen team should know exactly what will need to be done in order to implement the devised future state workflow.

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Do

1st cycle - Establish the current workflow

Do 1st cycle

Establish the current workflow

The first task in a Kaizen Event is to map the current workflow of the process under study. The deliverables from either of the Time-Motion or Work-Sample process mapping methodologies could be used here if they were already completed; however, traditionally, in a Kaizen Event, this current process mapping is created collaboratively by the Kaizen Team.

At the start of the event, it is most effective to select one person to be the diagram drawer (this person usually being one of the Kaizen experts). Then, going through the process step by step, the drawer takes input from the domain process experts as to how each step is conducted. The advantage to having the collaborative Kaizen team together during this process is that for each step, each member of the team can provide their unique perspective on the tasks; thus, creating the opportunity to draw the complete process (as opposed one domain’s restricted view of the process). For example, a physician and a nurse may have completely different ideas about the patient admission process; however, when they discuss the process together, it provides them with the opportunity to clarify their views, so that they can collaboratively map a process that is agreeable between both parties.

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1st cycle - Value Stream Mapping

Do 1st cycle

Value Stream Mapping

The standard diagramming format used for process mapping during a Kaizen Event is a Value Stream Map (VSM). A VSM is a “graphic map of steps that occur from the specific request for a product or service to the delivery of that product or service” (Jimmerson, 2007). Value Stream Mapping breaks down a process into a set of finite activities, which can then be analyzed to determine which activities are value-added (directly relational to the goal of the overall process), and which activities are non-value-added (not relational to the goal of the overall process).

VSMs should be drawn in pencil (free-hand), so that they can be quickly altered and remodelled during the collaborative drawing process. The diagrams should also follow a pre-defined VSM symbol schema (such as the one defined by (Jimmerson, 2007) - see figure 4). Any new symbols used in the diagram (not included in the VSM schema) should be included in a legend on the diagram.

An example of a completed, current state VSM is shown in figure 5. In this diagram, a basic patient check-up process is shown (in accordance with the VSM symbol schema defined in figure 4). During this fictitious example process:

1. the patient enters the waiting room of the clinician’s office;
2. the patient is admitted to the clinic by the secretary, who then prepares the patient’s chart and notifies the physician that the patient is ready via a pager;
3. the patient then waits in the waiting room until an available exam room is made ready;
4. the patient is then taken to the examination room where he/she can get prepared for the exam (i.e. change into the dressing gown)
5. the physician enters exam room when the patient is ready and conducts the examination
6. the physician makes a diagnosis (which requires a prescription), and calls in the prescription to a pharmacy (using the telephone in the next room)
7. the patient then gets changed, leaves the examination room, and goes to the pharmacy to pick up the prescription.

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1st cycle - Figure 4: Value Stream Mapping Legend

Value Stream Mapping Legend

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1st cycle - Figure 5: Current State Value Stream Map Example

Figure 5: Current State Value Stream Map Example

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1st cycle - Value Stream Map

Do 1st cycle

Stream Map (VSM)

The process diagram shows the interactions of the people and objects in the upper half of the diagram, along with the broken-down process activities and their timing in the bottom half of the diagram. The timing in the diagram can first be estimated by the Kaizen team during the workflow brainstorming session; however, the actual measured times should be substituted into the diagram after the VSM validation stage is completed (see ‘VSM Validation’). The cyclical timing chart at the bottom of the diagram clearly shows which process activities are value-added (i.e. a patient examination) at the top of the cycles, and which activities don’t add value to the overall goal of the process (i.e. waiting for the exam room) at the bottom of the cycles. The storm clouds in the diagram make special note of the problematic areas of the VSM.

This completed VSM not only shows the process as a whole, but each individual process component (activities) required to fulfill that process. As all VSMs are required, this map monitors the flow of a product (i.e. the patient) through a process, from when the process was first initiated (i.e. the patient enters the physician’s office), to when the process is completed (i.e. the prescription is dispensed and given to the patient). The current state VSM enables the Kaizen team to establish the ‘value quotient’, which is the value-added process time over the total process time (the value-added process time plus the non-value-added process time). This value quotient shows what percentage of the total process time is actually spent working towards the process goal. In the example defined in figure 5, only 29.4% of the process time is value-added, meaning the remaining 70.6% of the process time does not add value to the overall goal of the process (which in this case is treating the patient). With the knowledge of the value quotient, coupled with the breakdown of the value-added vs. non-value-added process activities, a Kaizen team can focus its attention on determining the means to reducing or removing the non-value-added activities from the process under study, and improving those activities that add value to the overall process.

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1st cycle - VSM Validation

Do 1st cycle

VSM Validation

After the VSM is completed, it should be validated through real-life observations. During this stage, the Kaizen team should break apart into small groups and observe the process in its natural environment. If, for any reason, actual observations cannot be made, process simulations can be conducted in their place (i.e. one of the Kaizen team members can pretend to be the patient making his/her way through the care process). The process should be timed and analyzed from the first activity, to the last. These validating measures should be taken at least once (preferably multiple times) to assure that they accurately reflect the true process.

After the observations are taken, the observational groups should reconvene, and share their results. If there are any discrepancies between the groups’ measurements, the groups should attempt to resolve their differences through discussion; however, if a consensus on the measurements cannot be reached, the groups should return to the field and collect additional measures. If the group is in agreement about the accuracy of the observed measures, yet a discrepancy between the measures and the VSM still exist, then the VSM should be revised to account for the differences. If the VSM is revised after the observational period, then the diagram should be re-validated through additional observations. If there are no discrepancies between the group’s measurements or between the observations and the VSM, then the Kaizen team can move to the next phase of the Kaizen Event (STUDY).

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2nd cycle - Test the ideal workflow

Do 2nd cycle

Test the ideal workflow

The next stage in the Kaizen Event involves testing the devised workflow solution. There may be cause to perform these tests through simulation (i.e. if it’s impossible to rapidly implement an IT aspect of the solution, or if the process solution poses any danger to the safety of the patients if it doesn’t go according to plan); however, ideally, the future state workflow test should be performed in natural conditions (i.e. real patients, with real systems) to get the best results.

The workflow test should be conducted in the same way as the current workflow VSM validation (the Kaizen team breaks off into groups who observe, time, and analyze the work being performed under natural conditions).

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Study

1st cycle

Study 1st cycle

Determine the problems with the current workflow

The ‘7 Mudas’ of Healthcare

Adapted from Taichi Ohno’s ‘7 Mudas’ (or wasteful activities) of automotive production (Ohno, 1988), (Jimmerson, 2007) defines the following as the ‘7 Mudas’ of healthcare:

1. Confusion – people not knowing how to do their work or what work to do (i.e. inadequate training causing workflow inefficiencies in patient admission, due to staff not understanding their roles or how to effectively do their work)
2. Motion/Travel – the non-value-added time spent physically moving in a workspace (i.e. walking across the room to answer the phone)
3. Waiting – the time spent idly waiting for people, objects, etc. (i.e. a patient waiting in an exam room for a doctor)
4. Processing – any activity that does not add value from the costumer’s (i.e. the patient’s) perspective (i.e. administrative work)
5. Inventory – overabundant inventory that causes clutter and disorganization (i.e. difficulty in finding a patient’s most recent check-up information due to its storage in a file that contains hundreds of disorganized pages from decades of consultations)
6. Defects – work that contains errors or lacks value (i.e. an un-noticed misdiagnosis)
7. Over-production – re-work (i.e. a physician writing both a paper and an electronic entry for a prescription order)

The ‘5 Whys’

With the ‘7 Mudas’ in mind, the Kaizen team can step through each of the process steps defined in the current state VSM (created in the previous phase), and determine which areas of the process under study are wasteful. This should be a collaborative effort between both the domain specialists (who will have a better understanding of the process workflow) and the Kaizen experts (who will have a better understanding of the Mudas and how/why they occur in a workflow). This can be accomplished by applying the ‘5 Whys’ lean tool, where first, a problem is identified, and then the root of that problem is derived by asking the question ‘Why?’ five consecutive times. For instance, in the case described in the VSM example (see figure 5), a Kaizen expert would immediately point out the ‘Waiting’ Muda described in the ‘Admission’ activity, and ask the question:

• Why – does the patient have to wait during the admission activity?

The secretary representative in the Kaizen team could then describe why they feel the patient is forced to wait for such a long time (since they are the ones most involved in the admission process). The secretary could point out a problem such as the fact that the patient has to wait because there is no examination room for the patient to move to. The Kaizen expert could then ask:

• Why is there no examination room for the patient to move to?

The secretary could respond to this with the fact that there are only two examination rooms in the office, and they are normally both occupied with patients (one room has the patient that is currently under examination, and the second room has the previous patient who has to prepare themselves to leave the office). The Kaizen expert could then ask:

• Why does it take so much time for the patient to prepare themselves to leave the office?

The physician representative could then step in and respond that the patients usually have to change into a dressing gown during the examinations, so after the examinations are completed, they normally have to put their clothes back on, which can take some time (especially for senior or disabled patients). This could be responded to by the Kaizen expert with:

• Why do the patients have to get changed in the examination room?

This would again be responded to by the physician, who would tell the Kaizen expert that they need to get changed in the examination room because there are no other rooms in the physician’s office to get changed in. This would bring up the final and most revealing question by the Kaizen expert:

• Why does your office not have a changing room?

This process could then be repeated to identify the root causes of the remaining problems found in the VSM. It is imperative that the roots of the process inefficiency problems are exposed before moving to the next stage of the Kaizen Event (ACT), because solutions developed for misunderstood problems almost always result in either temporary (band-aid) fixes or, more frequently, no improvements whatsoever.

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2nd cycle

Study 2nd cycle

Analyze the implementation test results

The second STUDY cycle of the Kaizen Event should be performed in the same way as the first STUDY cycle, except that instead of analyzing the results from the current workflow observations, it is the revised workflow that is under study. In this phase, the Kaizen team will:

• Collaboratively discuss their observational findings
  • Were there any observational discrepancies between the groups?
    • If so, then the groups must either resolve the discrepancies through discussion, or re-do the revised workflow observational test.
  • Were there any discrepancies between the future state VSM and what occurred in the test/simulation
    • If so, then either the VSM should be updated to indicate the actual process activities/timing, or the implementation plan or the test will need to be re-evaluated. The process plan re-evaluation should assure that the right process changes are being made and the process test re-evaluation should assure that the right measurements are being used to capture those changes.
  • Were there any marked improvements after the changeover from the current state workflow to the future state workflow?
    • If no, then the Kaizen team should re-evaluate their previous work (as they may need to back-track in order to: produce a more accurate current state, derive the current state root problems, or create better solutions).
    • If yes, then is there any other means to improve the new workflow?
      • If yes, then collaboratively brainstorm the ideas, then re- test and re-evaluate the solution.

For the future state VSM example (see figure 6), in all, 62 minutes were removed from the total process time. The total process time was lowered from 163 minutes in the current state workflow down to 101 minutes in the future state workflow. The value quotient also has improved from 29.4% to 40.6%, showing that a greater proportion of the process time in the future state is oriented towards the process goal (patient care).

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Act

1st cycle - Muda Countermeasures

Act 1st cycle

Muda Countermeasures

Once the core Mudas are exposed in the current workflow, it is possible to stop the problems at their source. In (Jimmerson, 2007), a set of general countermeasures were created to apply to each of the Mudas. They are:

1. Confusion – create clear and concise written descriptions for all work activities to help guide the staff. All activities should also have clear signals that indicate when an activity has started or stopped.
2. Motion/Travel – IT communication systems can be used to minimize physical travel. Information and materials should be available on-demand, in easily accessible areas.
3. Waiting – Just-in-time scheduling should be used to provide people with what they want, when they want it. Large meetings should also be minimized (and replaced with smaller focus groups).
4. Processing – The work area should be re-designed to create continuous flow. Only essential information should be kept in the patient files.
5. Inventory – Keep only the essential supplies to avoid clutter. The ‘essentials’ should be custom-tailored to meet the needs of each unique working team.
6. Defects – There should be a general consensus on what is deemed ‘defect free’, so that this goal can be reached for all processes and products.
7. Over-production – Process regulations should be well defined and understood by all. All systems (electronic or paper) should be integrated to avoid duplication.

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1st cycle - 5S

Act 1st cycle

5S

Another Lean tool that can be used to eliminate the waste found in the current workflow is the ‘5S’ approach:

1. Sort – Eliminate all unessential inventory to free up storage space and decrease search times.
2. Straighten – Organizing and categorizing the workspace can also greatly improve search times.
3. Shine – Cleaning the workplace facilitates easier access to desired equipment. Equipment that requires assembly before use should have clear instructions on how to perform the assembly, and all required tools and equipment needed to assemble the device should be adjacent to it.
4. Standardize – Organization-wide standards should be created to assure that the same organizing, categorizing, cleaning, instructional, etc. methods are used across practice. This will greatly speed up the learning period for all of the 5S tasks.
5. Sustain – The 5Ss should be periodically re-evaluated (from top to bottom) to assure that the working environment is constantly the best it can be.

(Jimmerson, 2007)

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1st cycle - Create the ideal workflow

Act 1st cycle

Create the ideal workflow

Using the previously defined Muda countermeasures, 5Ss, and general collaborative brainstorming, the Kaizen team must revise the current workflow to remove as much waste as possible. Experts in Kaizen/Lean tools, healthcare domains, and information technology can all come together in this phase to develop the ideal workflow solutions that will work for all parties involved. When developing the new, ideal workflow, it too should be diagramed using a VSM (see the Value Stream Mapping section for instructions).

For the previous VSM example, it was determined in the study phase of the Kaizen event that one of the main problems that was slowing down the process time was the fact that the examination rooms were being tied up with patients having to change in them, both before and after the examinations. During the ideal workflow brainstorming session, it would likely be suggested that a separate changing room is installed in the doctor’s office to eliminate this extra delay. This change would result in more time available in the examination rooms, which would allow the physicians to see more patients, and thus, would shorten the waiting periods for the patients as well.

For the future state VSM diagram (see figure 6), the added changing room is just one of several improvement strategies developed by the Kaizen group. An EMR system with CPOE functionality was also put into the clinic to automate the patient records keeping and prescription ordering processes. The EMR in this example can also be used to improve communication between the secretary and the physician through automated notification (from the EMR to the physician’s pager) of patients’ appointments.

With these changes, the Kaizen team will hope to dramatically improve the patient care process time; however, in order to be assured that these revisions can actually create the envisioned improvements, this future state workflow will first have to be implemented and tested via a second cycle of PDSA.

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1st cycle - Figure 6: Future State Value Stream Map Example

Figure 6: Future State Value Stream Map Example

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2nd cycle - Implement the ideal workflow

Act 2nd cycle

Implement the ideal workflow

The final stage of the Kaizen Event is entirely dependent on whether or not the previous stages were successful or not. If the previous stages of the Kaizen Event weren’t successful, then they must be re-performed, in order to devise a workable solution. If, however, the test implementation of the future state workflow proved to be successful, then a full-scale implementation of the new workflow can be conducted. A follow-up evaluation of the revised workflow should also be scheduled in order to assure its continual quality.

Finally, it is recommended that a Kaizen Event closeout meeting is held on the final day of the Kaizen Event. Such meetings should involve all relevant stakeholders, and should both summarize the accomplishments of the event and celebrate the achievements made by the Kaizen Event team.

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PDSA Summary

1st cycle

PDSA Summary 1st cycle

Plan

• Form the Kaizen team
• Plan the Kaizen meeting and provide information about the Kaizen Event to the team in advance

Do

• Define the current workflow using either a previously performed workflow analysis (e.g., Time-Motion or a Work-Sample study), or by developing a current workflow description
• Draw a Visual Stream Map (VSM)¹

Study

• Identify wasteful activities (Mudas ) in the system through collaborative brainstorming, such as: confusion, motion/travel, waiting, processing, inventory, defects, and overproduction
• Apply the “5 Whys Lean Tool²” to expose the core problem of each “Muda”

Act

• Collaboratively brainstorm solutions to correct the “Mudas” in the current workflow
• Use “Muda countermeasures” and the five S’s (Sort, Straighten, Shine, Standardize, and Sustain) to remove the “Mudas” (Jimmerson, 2007)
• Draw a Visual Stream Map to clearly define what the new process will look like

¹ Value Stream Map (VSM) is a “graphic map of steps that occur from the specific request for a product or service to the delivery of that product or service” (Jimmerson, 2007). Value Stream Mapping breaks down a process into a set of finite activities, which can then be analyzed to determine which activities are value-added (directly relational to the goal of the overall process), and which activities are non-value-added (not relational to the goal of the overall process).

² 5 Whys lean tool

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2nd cycle

PDSA Summary 2nd cycle

Plan

• Create a plan to implement the new workflow

Do

• Test the future state workflow by implementing (or simulating) the workflow changes
• Break the Kaizen Team into groups to observe and measure the revised workflow in action

Study

• Reconvene the Kaizen team and discuss the test findings
• If any issues are identified (i.e. the observations produced inconsistent results), then the test plan should be re-evaluated and then performed again
• If problems are found with the test results (i.e. little or no improvements in the future state workflow implementation), re-evaluate decisions made in previous phases of the Kaizen Event
• Make final revisions to the future state workflow, and then test and study them before full scale implementation

Act

• If the test was unsuccessful:
  1. Redesign the solution
• If the test implementation was successful:
  1. Conduct the full-scale implementation
  2. Schedule and conduct a follow-up review
  3. Conduct a Kaizen Event close-out meeting

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References

References

• Black, J., & Miller, D. (2008). THE TOYOTA WAY TO HEALTHCARE EXCELLENCE - INCREASE EFFICIENCY AND IMPROVE QUALITY WITH LEAN. Chicago: Health Administration Press.
• Jimmerson, C. (2007). reVIEW - realizing exceptional VALUE IN EVERYDAY WORK (Seconnd Edition ed.). Bozeman, Montana: Healthcare Performance Partners - Lean Healthcare West.
• Ohno, T. (1988). Toyota Production System - Beyond Large-Scale Production. Productivity Press .

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