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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 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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neOnatOLOGY
anesthesiOLOGY
emerGencY
radiOLOGY
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?
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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.
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
• 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.
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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 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.
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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.
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 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.
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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:
leadersHip drives perfOrMance • page 10
anesthesiOLOGY emerGencY radiOLOGY
OutsOurced clinical & ManageMent services
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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