kaizen workshops for lean healthcare

Part of the Lean Tools for Healthcare series, this user-friendly book will help to improve your understanding of kaizen. It describes exactly what a kaizen event is and details all the phases necessary for implementing continuous improvement practices in your healthcare organization.

Kaizen Workshops for Lean Healthcare walks you through the steps of conducting an effective kaizen workshop—one that is well planned, well implemented, and well monitored. The information is presented in an easy-to-assimilate format. Numerous illustrations reinforce the text, and margin assists call your attention to key terms, healthcare examples, and how-to steps.

Throughout the book, you will be asked to reflect on questions that will help you apply the concepts and techniques in your own workplace. Defining the key concepts and elements of the “production” of healthcare services, the text delineates the differences between healthcare processes and the individual cycles of work that those processes link together. It also:

• Provides foundational information on kaizen and kaizen workshops—defining the key roles for success

• Explains exactly how to plan and prepare

• Presents examples of how to present workshop results and how to follow up

• Includes a concise summary of kaizen workshop steps

• Supplies a list of additional resources for learning more about the different kinds of improvement methodologies you might want to implement in your kaizen workshops

If your healthcare organization fully applies the steps detailed in this book, it will gain much more than the knowledge of how to conduct a workshop. Through kaizen, you will empower your employees to make positive change a reality. And incrementally, kaizen workshops will become more than isolated events—they will become the way all work is done in your organization.

Kaizen Workshopsfor Lean HealthcareRona Consulting Group & Productivity PressThomas L. Jackson, Editor

KA

IZEN W

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Kaizen Workshops for Lean HealthcareRona Consulting Group & Productivity Press

Thomas L. Jackson, Editor

www.product iv i t ypress .com

www.crcpress.com

ISBN: 978-1-4398-4152-5

9 781439 841525

90000

K11931

Business & Management / Healthcare Process Improvement

Rona Consulting Group • Jackson

Lean Tools for Healthcare Series

K11931 cvr mech.indd 1 7/24/12 11:21 AM

Kaizen Workshopsfor Lean Healthcare

Kaizen Workshopsfor Lean Healthcare

Rona Consulting Group & Productivity Press


CRC PressTaylor & Francis Group6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

© 2013 by Taylor & Francis Group, LLCCRC Press is an imprint of Taylor & Francis Group, an Informa business

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v

Contents

Preface.......................................................................................................... ix

Acknowledgments........................................................................................xi

1 Getting.Started....................................................................................... 11.1 PurposeofThisBook........................................................................11.2 WhatThisBookIsBasedOn............................................................11.3 TwoWaystoUseThisBook.............................................................21.4 HowtoGettheMostOutofYourReading......................................2

1.4.1 BecomeFamiliarwithThisBookasaWhole........................21.4.2 BecomeFamiliarwithEachChapter.......................................31.4.3 HowaReadingStrategyWorks...............................................31.4.4 UsingtheMarginAssists.........................................................4

1.5 AnOverviewoftheContents............................................................51.5.1 Chapter1:GettingStarted.......................................................51.5.2 Chapter2:ProductionProcesses andOperationsof

Healthcare................................................................................51.5.3 Chapter3:WhatIsKaizen?.....................................................51.5.4 Chapter4:WhatIsaKaizenWorkshopandWhatAre

theKeyRolesforSuccess?.......................................................51.5.5 Chapter5:PhaseOne:PlanandPrepare................................... 51.5.6 Chapter6:PhaseTwo:RuntheKaizenWorkshop.................61.5.7 Chapter7:PhaseThree:ReportandFollow-Up.....................61.5.8 Chapter8:ReflectionsandConclusions..................................6

2 Production.Processes and.Operations.of.Healthcare........................... 72.1 IndustrialOrigins ofLeanHealthcare...............................................72.2 Production,Process,andOperation..................................................92.3 Summary...........................................................................................112.4 Reflections........................................................................................12

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3 What.Is.Kaizen?................................................................................... 133.1 WhatIsKaizen?................................................................................13

3.1.1 KaizenandKaikaku..............................................................143.1.2 WhatDoYouNeedtoKnowtoFully Understand

How toDoKaizen?...............................................................153.1.3 HowWillKaizenChangeWhatYouAreDoingNow?..............16

3.2 WhatIsthePurposeofKaizen?......................................................163.2.1 ProcessandOperation..........................................................163.2.2 ValueandValue-Added.........................................................163.2.3 Waste......................................................................................18

3.3 WhatIstheRoleofaKaizenWorkshop?.................................................... 193.4 BenefitsofKaizenandKaizen Workshops.....................................20

3.4.1 HowDoesKaizenBenefitYourHealthcareOrganization?...203.4.2 HowDoesKaizenBenefitYou?............................................20

3.5 Summary...........................................................................................203.6 Reflections........................................................................................22

4 What.Is.a.Kaizen.Workshop.and.What.Are.the.Key.Roles.for.Success?................................................................................................ 234.1 WhatIsaKaizenWorkshop?...........................................................234.2 HowIsaProblemSelected?.............................................................244.3 Cautions............................................................................................24

4.3.1 PlaninAdvanceforCoverage...............................................254.3.2 PuttheFocusonClinicianandStaffMemberParticipation...254.3.3 UnderstandtheImportanceofPreparationandFollow-Up....30

4.4 SuccessfulKaizeninAction.............................................................304.5 WhatAretheKeyRolesforaSuccessfulKaizenWorkshop?.........32

4.5.1 WorkshopLeader...................................................................334.5.2 Sponsor..................................................................................354.5.3 TheUnionRole......................................................................354.5.4 ProcessOwner.......................................................................36

4.6 CommunicatingtotheWholeHealthcareOrganizationabouttheKaizenWorkshop.......................................................................37

4.7 ThreePhasesof aKaizenWorkshop..............................................384.8 Summary...........................................................................................384.9 Reflections........................................................................................40

5 Phase.One:.Plan.and.Prepare.............................................................. 415.1 SelectanArea...................................................................................41

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5.2 SelectaProblemforImprovement..................................................455.2.1 EliminationofWasteasanOverallFocus............................45

5.3 SpecialConsiderationsinChoosing aProblemforImprovement....485.3.1 Implementing5S....................................................................485.3.2 ImplementingStandardWork...............................................505.3.3 EliminatingBottlenecksorImprovingSetupTimes.............505.3.4 ImplementingContinuousFlow,LineBalancing,

or Kanban..............................................................................515.4 SelectandPreparetheTeam...........................................................52

5.4.1 SelecttheTeamLeader..........................................................525.4.2 PreparetheTeamLeader.......................................................525.4.3 SelecttheTeamMembers......................................................53

5.5 OtherPreparations...........................................................................585.5.1 PreparetheArea....................................................................585.5.2 PrepareSupplies,Equipment,andSupportPeople..............595.5.3 GatherBackgroundInformation...........................................595.5.4 ScheduletheWorkshop.........................................................60

5.6 Summary...........................................................................................645.7 Reflections........................................................................................67

6 Phase.Two:.Run.the.Kaizen.Workshop............................................... 696.1 Orientation........................................................................................69

6.1.1 IntroducetheTeamandAssignRoles..................................696.1.2 IntroducetheWorkshopObjectivesandProcedures...........706.1.3 DistributeTeamSupplyKitsandResources.........................716.1.4 ConductLeanHealthcareTraining.......................................726.1.5 SetGroundRules...................................................................73

6.2 UnderstandtheCurrent SituationintheGemba............................746.2.1 ObservetheSelectedAreaandGatherData........................746.2.2 ReviewtheValueStreamMap...............................................756.2.3 DoTimeStudiesofAllOperations.......................................79

6.3 DevelopImprovements....................................................................806.3.1 GenerateandCaptureImprovementIdeas...........................80

6.4 FacilitateTeamwork..........................................................................816.5 TestIdeasandImplement theNewPlan.........................................826.6 DevelopNewStandards...................................................................856.7 Summary...........................................................................................856.8 Reflections........................................................................................87

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7 Phase.Three:.Report.and.Follow-Up................................................... 897.1 Presentation......................................................................................89

7.1.1 PrepareaPresentationofAll Data andWorkshopResults....897.1.2 PresenttheResults.................................................................907.1.3 CoverIdeasThatHaveNotBeenFullyImplemented.........927.1.4 BuildtheBookofKnowledge..............................................927.1.5 CirculateandDisplayResults................................................93

7.2 Follow-Up.........................................................................................937.3 Summary...........................................................................................957.4 Reflections........................................................................................97

8 Reflections.and.Conclusions................................................................ 998.1 SummaryofStepsforConductingaKaizenWorkshop.................99

8.1.1 PhaseOne:PlanandPrepare................................................998.1.2 PhaseTwo:RuntheKaizenWorkshop.................................998.1.3 PhaseThree:ReportandFollow-Up...................................100

8.2 ReflectingonWhatYouHaveLearned......................................... 1018.3 OpportunitiesforFurtherLearning............................................... 1018.4 Summary.........................................................................................102

Appendix........................................................................................................103FurtherReading......................................................................................103UsefulWebsites.......................................................................................103

ix

Preface

Kaizenmeans,simply,continuous improvement.Itisbasedonthefundamen-talsofscientificanalysisinwhichyouanalyze(takeapart)theelementsofaprocessorsystemtounderstandhowitworkssothatyoucanlearnhowtoinfluenceit(makeitbetter).KaizenisthebuildingblockofalltheLeanhealth-caremethodologies;itisthefoundationuponwhichallofthesemethodshavebeenbuilt.Thesmall,gradual,incrementalchangesofcontinuousimprove-mentappliedoveralongperiodadduptomajorpositiveimpactsonpatients’accesstohealthcare,patientsafety,andthequalityofmedicalresults.

Onceyourhealthcareorganizationhascommittedtosupportingacultureof continuous improvement,kaizenworkshopscanbeheldperiodically tomakefocusedchangesintheworkplace.Theseworkshopswilltakeamagni-fyingglass,sotospeak,toeachprocessandeveryoperationinthemedicalcenterinordertoeliminatewasteandimproveservices.

Thisbookwaswrittentotakeyouthroughthestepsofconductingaveryeffectivekaizenworkshop—onethatiswellplanned,wellimplemented,andwellmonitoredaftersaidchangesareimplemented.Theinformationispre-sentedinahighlyorganizedandeasy-to-assimilateformat.Numerousillustra-tionsreinforcethetext,andmarginassistscallyourattentiontokeypointsandotherimportantfeatures.Throughoutthebook,youareaskedtoreflectonquestionsthatwillhelpyouapplytheseconceptsandtechniquestoyourownworkplace.Eachchapterhasasummaryforquickreview.

Chapter 1helpsyouget startedby suggesting strategies for readingandlearning,explainstheinstructionalformatofthebook,andprovidesanover-viewofeachchapter.Chapter2definesthekeyconceptsandexplorestheelementsofthe“production”ofhealthcareservices.Italsoexplainsthekeydifferences between healthcare processes and the individual operations orcyclesofworkthatprocesseslinktogether.Chapters3and4providefoun-dational informationforkaizenandkaizenworkshopsandexplainthekeyrolesforsuccess.Chapter5explainsplanningandpreparation,andChapter 6

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coversimplementation.Chapter7includesexamplesofhowtopresentyourworkshop results to the organization and how to follow up. It is throughgoodfollow-upthatyoureapfullbenefitsfromkaizen.Chapter8presentsaconcisesummaryofkaizenworkshopsteps.Finally,theAppendixprovidesalistofadditionalresourcesforlearningmoreaboutthekindsofimprovementmethodologiesyoumightwanttoimplementwithkaizenworkshops.

Ifyourhealthcareorganizationfullyappliesthestepsinthisbooktocon-ductingkaizenworkshops, itwill gainmuchmore than theknowledgeofhowtoconductaworkshop.Throughkaizen,employeesareempoweredandencouragedtomakepositivechanges.Becausetheywillpracticeworkinginteams, theorganizationwill reap thesynergy thatcomes fromacollectivefocus on improvement. And incrementally, kaizenworkshopswill becomemorethanisolatedevents—theywillbecomethewayallworkisdone.

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Acknowledgments

ThedevelopmentofKaizen for Lean Healthcarehasbeenateameffort.Inparticular,IwouldliketothankSusieCreger,ErinRessler,AnnKernan,RonaConsultingGroupconsultantsandformerteammembersoftheVirginiaMasonKaizenPromotionOffice,forexpertlyeducatingandcoachingtheseniorlead-ersofourhealthcareclientsonhowtorunagoodkaizenworkshop.ThanksalsotoalloftheRonaConsultingGroupconsultantswhohavecontributedtoourworkshopstandardwork.A lothappens in thecourseoffivedays,especiallywhenyourimprovementteamistopheavywithtalenteddoctorsandnurses.Thankyouforhelpingourclients(andmepersonally)keeptrackofitall.Finally,I wouldalsoliketothankthemanytalentedpeopleoftheProductivityPressDevelopmentTeam,especially JudithAllen,whocreatedtheoriginalbook,Kaizen for the Shop Floor,uponwhichthisbookisbased.

WeareverypleasedtobringyouthisadditiontoourLeanToolsforHealthcareSeriesandwishyoucontinuedandincreasingsuccessonyourLeanjourney.

ThomasL.Jackson,SeriesEditor

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Chapter 1

Getting Started

1.1 PURPOSE OF THIS BOOK

Kaizen for Lean HealthcarewaswrittentogiveyoutheinformationyouneedtoparticipateinimplementingthisimportantLeanhealthcareapproachinyourworkplace.Youareavaluedmemberofyourhealthcareorganiza-tion’stransformationteam;yourknowledge,support,andparticipationarenecessary to thesuccessofanymajorimprovementeffortinyourorganization.

You may be reading this book because your teamleaderormanageraskedyoutodoso.Oryoumaybereadingitbecauseyouthinkitwillprovideinformationthatwillhelpyouinyourwork.BythetimeyoufinishChapter1,youwillhaveabetterideaofhowtheinfor-mationinthisbookcanhelpyouandyourhealthcareorganization eliminate waste and serve your patientsmoreeffectively.

1.2 WHAT THIS BOOK IS BASED ON

Thisbookisaboutkaizen,acriticaltoolforimplement-ingLeanhealthcareservicesandeliminatingwastefromhealthcareprocesses.Kaizenisamethodologyofcon-tinuous, incremental improvement. Kaizen workshopsareusedtobringquickandfocusedimprovementsandmake significant changes in the way processes workand areas function. Themethods and goals discussedinthisbooksupporttheLeanhealthcaresystemdevel-opedatToyotaMotorCompany.Since1979,ProductivityPresshaspublishedinformationabouttheseapproaches.Since2007,RonaConsultingGrouphasbeenapplyingtheknowledgeontheshopfloorofhealthcare.Today,

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toporganizationsaroundtheworldareapplyingLeanhealth-careprinciplestoimprovepatientsafetyandmakehealthcaremoreaffordable.

Kaizen for Lean Healthcare draws on a wide variety ofresources.Itsaimistopresentthemainconceptsandstepsofrunningkaizenworkshopsinasimple,illustratedformatthatiseasytoreadandunderstand.

1.3 TWO WAYS TO USE THIS BOOK

Thereareatleasttwowaystousethisbook:

1.As reading material for a learning group or studygroupprocesswithinyourorganization

2.Forlearningonyourown

Yourorganizationmaydecide todesign itsown learninggroupprocessbasedonKaizen for Lean Healthcare.Alterna-tively,youmayreadthisbookforindividuallearningwithoutformalgroupdiscussion.Eitherway,youwilllearnvaluableconceptsandmethodstoapplytoyourdailywork.

1.4 HOW TO GET THE MOST OUT OF YOUR READING

1.4.1 Become Familiar with This Book as a Whole

There are a few steps you can follow tomake it easier toabsorbtheinformationinthisbook.Takeasmuchtimeasyouneed tobecomefamiliarwith thematerial.First,geta“bigpicture”viewofthebookbydoingthefollowing:

◾ ScantheTableofContentstoseehowKaizen for Lean Healthcareisarranged.

◾ Readtherestofthisintroductorysectionforanover-viewofthebook’scontents.

◾ Flipthroughthebooktogetafeelforitsstyle,flow,and design. Notice how the chapters are structuredandglanceattheillustrations.

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1.4.2 Become Familiar with Each Chapter

AfteryouhaveasenseoftheoverallstructureofKaizen for Lean Healthcare,prepareyourselftostudyonechapteratatime.Foreachchapter,wesuggestyoufollowthesestepstogetthemostoutofyourreading:

◾ Flipthroughthechapter,lookingatthewayitislaidout. Notice the bold headings and the key pointsflaggedinthemargins.

◾ Nowreadthechapter.Howlongthistakesdependsonwhatyoualreadyknowaboutthecontentandwhatyou are trying to get out of your reading. Enhanceyourreadingbydoingthefollowing:

− Usethemarginassiststohelpyoufollowtheflowofinformation.

− Ifthebookisyourown,useahighlightertomarkkey information and answers to your questionsabout thematerial. If thebook isnot yourown,takenotesonaseparatepieceofpaper.

− AnswertheTakeFivequestionsinthetext.Thesewillhelpyouabsorbtheinformationbyreflectingonhowyoumightapplyittoyourownworkplace.

◾ Read the Summary at the end of the chapter toreinforcewhatyouhavelearned.Ifyoureadsome-thingintheSummarythatyoudon’tremember,findthatsectioninthechapterandreviewit.

◾ Finally,readtheReflectionsquestionsattheendofthechapter.Thinkaboutthesequestionsandwritedownyouranswers.

1.4.3 How a Reading Strategy Works

Whenreadingabook,manypeoplethinktheyshouldstartwiththefirstwordandreadstraightthroughuntiltheend.Thisisnotusuallythebestwaytolearnfromabook.Thestepsjustsuggestedforhowtoreadthisbookareastrategyformakingyourreadingeasier,morefun,andmoreeffective.


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Readingstrategyisbasedontwosimplepointsaboutthewaypeoplelearn.Thefirstpointisthis:It’s difficult for your brain to absorb new information if it does not have a struc-ture to place it in. Asananalogy,imaginetryingtobuildahousewithoutfirstputtingupaframework.

Likebuildingaframeforahouse,youcangiveyourbrainaframeworkforthenewinformationinthebookbygettinganoverviewof thecontentsand thenflipping through thematerial.Withineachchapter,yourepeatthisprocessonasmallerscalebyreadingthekeypointsandheadingsbeforereadingthetext.

Thesecondpointaboutlearningisthis: It is a lot easier to learn if you take in the information one layer at a time, instead of trying to absorb it all at once.It’slikepaintingthewallsofahouse:Firstyoulaydownacoatofprimer.Whenthatisdry,youapplyacoatofpaint,andlaterafinishcoat.

1.4.4 Using the Margin Assists

Asyou’venoticedbynow,thisbookusessmallimagescalledmargin assists to help you follow the information in eachchapter.Thereareseventypesofmarginassists:

1.BackgroundInformation:Setsthestageforwhatcomesnext

2.Definition:Defineshowtheauthoruseskeyterms

3.KeyPoint:Highlightsimportantideastoremember

4.Example:Helpsyouunderstandthekeypoints

5.NewTool:Helpsyouapplywhatyouhavelearned

6.How-toSteps:Givesyouasetofdirectionsforusingnewtools

7.Principle: Explains how things work in a variety ofsituations

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1.5 AN OVERVIEW OF THE CONTENTS

1.5.1 Chapter 1: Getting Started

ThischapterhasalreadyexplainedthepurposeofKaizen for Lean Healthcareandhowitwaswritten.Thenitsharedtipsforgettingthemostoutofyourreading.Itwillnowgiveabriefdescriptionofeachchapter.

1.5.2 Chapter 2: Production Processes and Operations of Healthcare

Chapter2describestheindustrialoriginsoftheLeanhealth-caremethodologyandexplainsthecriticaldistinctionbetweenhealthcareprocessesandhealthcareoperations.

1.5.3 Chapter 3: What Is Kaizen?

Chapter3introducesanddefineskaizenanditspurposefortheworkplace.Theconceptsofvalue,value-added,andwastearedefinedinrelationtokaizen.Thischapteralsodiscusseswhatisneededtobesuccessfulinimplementingkaizenandexplains how kaizen and kaizen workshops benefit bothhealthcareorganizationsandtheiremployees.

1.5.4 Chapter 4: What Is a Kaizen Workshop and What Are the Key Roles for Success?

Chapter4describesakaizenworkshopandthekeyrolespeo-plemustplayforkaizenworkshopstobesuccessful.Cautionsaboutrunningkaizenworkshopsareexplained,includinganexamplebaseduponexperiencesatbothParkNicolletHealthServicesinMinneapolis,Minnesota,andtheVirginiaMasonMedicalCenter inSeattle,Washington.The roleofcommu-nicationinasuccessfulworkshopisdiscussedandthethreephasesofaworkshopareintroduced.

1.5.5 Chapter 5: Phase One: Plan and Prepare

Chapter5highlightsthekeystepsinpreparingforakaizenworkshop.Itdescribeshowtoselectanareaandchoosean

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improvementfocus.Animportantdiscussionaboutidentify-ingwaste is included.How to select the leader and team,andhow toprepare the area for thekaizenworkshopareexplained.Detailsabouttheteamleader’sroleandtoolsforthe team leader are provided. The chapter concludeswithinformationaboutschedulingtheworkshop.

1.5.6 Chapter 6: Phase Two: Run the Kaizen Workshop

Chapter6describesthedetailsinvolvedinrunningthework-shop and provides valuable documents to be used duringworkshopactivities.Howtounderstandthecurrentsituationandhowtobeginimprovements—developingimprovementideas, implementingnewplans, testing improvement ideas,anddevelopingnewstandards—areallexplained.

1.5.7 Chapter 7: Phase Three: Report and Follow-Up

Chapter7discussesthefinalphasewhereresultsofthekaizenworkshoparepresentedtotheentiremedicalcenter.Follow-upsteps must be developed to ensure that the improvementsbecomenewstandardsofoperation.Abriefcelebrationcanbeplannedtocongratulatetheteam.

1.5.8 Chapter 8: Reflections and Conclusions

Chapter8reflectsonandpresentsaconclusiontothisbook.It includes an implementation summary for conducting akaizenworkshop.

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Chapter 2

Production Processes and Operations of

Healthcare

2.1 INDUSTRIAL ORIGINS OF LEAN HEALTHCARE

Thepurposeof theLean Tools for HealthcareSeries istointroducereaderstoasetofmethodsthathavebeenproventodramaticallyincreasepatientsafetyandreducethecostofprovidinghealthcareservices.ThetermLeanwascoined toexpress thenotion that, likeanathlete,anorganizationshouldbewithoutorganizational “fat,”orwhat Lean specialists refer to as non-value-adding waste,where value refers towhat a patientwouldbewillingtopayfor.Figure 2.1listssevendistincttypesofwastefoundinhealthcare.

LeantoolsandmethodshaveimportantoriginsintheUnitedStatesbutwereperfectedprincipallywithintheToyota Motor Company between 1948 and 1963, andhave sincebeencopiedbymost sectorsof themanu-facturingindustry.Thefirstmajorimplementationinthehealthcare industry began in 2001, when the VirginiaMasonMedicalCenter inSeattle,Washington,engagedconsultants(mostofwhomhadbeenproductionengi-neersfromToyotaandtheBoeingAircraftCompany)toteachthemhowtoapplytheToyotaProductionSystemto the production of healthcare services. A few yearslater, another major implementation was launched by

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The Seven Major Categories of Healthcare Waste

Definitions Clinical Wastes Administrative Wastes

1. Excess production

Producing more, sooner, or faster than is required by the next process

Unnecessary tests or labsUnnecessary medicinesUnnecessary surgeries

“Copy all” emailstoo many reportstoo many meetingsextra copies

2. Waiting

time delays, process idle time

Waiting for lab resultsWaiting for doctorsWaiting for nursesWaiting for patients

Waiting for information system response

Waiting for approvals

3. Transport

Unnecessary handling or transportation; multiple handling

too many patient transferstransport of equipment

transport of paper medical records

transferring data files between incompatible information systems

4. Excess processing

Unnecessary processing, steps, or work elements or procedures

asking the patient the same question 20 times

Multiple entries of same information in patient charts

Long meetingsLong reportsreentering datareformatting presentations

5. Excess inventory

Producing, holding, or purchasing unnecessary inventory

Patients waitingtoo many suppliestoo many prosthetic devicesdoctor’s favorite supplies

decisions in processtoo much informationtoo many forms

6. Excess movement

excessive handling, unnecessary steps, nonergonomic motion

Walking all daystanding all dayLifting more than 35 poundsreaching, bending, twisting

sitting all dayWalking back and forth to printers, copiers, fax machines

reaching, bending, twisting

7. Defects

rework, correction of errors, quality problems, equipment problems

Hospital-acquired infectionsWrong medsWrong-side surgeriesWrong patientexpired suppliesPatient returns

order-entry errorsinvoice errorsoutdated informationoutdated forms

Figure 2.1 the seven wastes. (reprinted with permission. J. Michael rona and associates, LLC, doing business as rona Consulting Group © 2008–2012, http://www.ronaconsulting.com. all rights reserved.)

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ParkNicolletHealthServicesinMinneapolis,Minnesota,andafewotherorganizations,includingThedacareinWisconsin.Thesuccessoftheseimplementationsiswelldocumented.*

Naturally,readerscomingtothesubjectofLean health-care for thefirst timeareoftenperplexedbythepatentlyindustrialpointofviewtakenbyLeanhealthcarespecialists.Howcanhealthcarebetreatedasanindustrialprocess?Isn’tmedicineanart?Canhealthcareprocessesbestandardizedwhenallpatientsareunique?Infact,medicineandhealth-care practice are generally becoming more scientific orevidencebased,andtheCenterforMedicareandMedicaidServices (CMS) and deeming authorities such as the JointCommission are quick to require adherence to standard-ized, evidence-based practices. Moreover, industrial engi-neering has long been applied to healthcare processes.SomereadersmayrecallactorCliftonWeb’sportrayalofthetime-and-motion consultant Frank Gilbreth in the movie,Cheaper by the Dozen.ThemoviedepictsGilbreth’sground-breaking time and motion studies of surgery in hospitaloperatingrooms.Inmanyways,thepracticeofLeanhealth-carecontinuesinthetraditionofGilbreth’stimestudies.Themajordifference is that thestudiesarenotcarriedoutbyconsultants; thestudiesareconductedbymembersof thehealthcare team (clinicians and support staff), frequentlywiththevoluntaryparticipationofpatientsthemselves.

2.2 PRODUCTION, PROCESS, AND OPERATION

BeforestudyingLeanhealthcare,youmustunderstandpre-ciselyhowthenotionofproductionappliestotheproductionofhealthcareservices.†Asperplexingasitmayseem,produc-tionisnotnecessarilyanactivitythatrequiresmachines.

* JohnBlackwithDavidMiller,TheToyotaWaytoHealthcareExcellence:IncreaseEfficiency and Improve Quality with Lean (Chicago: Health AdministrationPress,2008).

† Muchofthischapterparaphrases,inlanguagefriendlytohealthcare,Chapter 1of Shigeo Shingo’s groundbreaking book, A Study of the Toyota Production System from an Industrial Engineering Perspective(Cambridge,MA:ProductivityPress,1989).

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Productionisthemakingofeitheraproductoraservice—itdoesn’t matter which. Obviously, artisans produced goodsandservicesbeforetheadventofsteampower.Initsmostgeneralsense,productionissimplyanetworkofwhatindus-trialengineerscallprocessesandoperations.

Aprocess is a sequenceof cycles ofwork calledopera-tions.Anoperationisaworkcycledefinedbyasequenceofspecifictasks.

Figure 2.2 illustrates how a healthcare process—trans-formingapatientfromthestateofunhealthytohealthy—isaccomplishedthroughaseriesofmedicalandotherhealth-careoperations.Whenwelookatahealthcareprocessovertime (especiallywhenwesee it from thepatient’sperspec-tive),weseeflowsofpatients,clinicians,medicines,supplies,equipment,and information in timeandspace.Wesee thetransformationof thepatient fromthemomentatwhichheorshepresentsundiagnosedsymptoms,toinitialassessment,definitivediagnosis,andfinallytreatmentandrecovery.Whenwelookatoperations,ontheotherhand,weseetheworkperformedby doctors, nurses, lab technicians, pharmacists,andothers,toaccomplishthistransformation—theinteractionofpatients,clinicians,medications,information,supplies,andequipmentintimeandspace.

Tomakefundamentalimprovementintheprocessofpro-ducinghealthcare services,wemust distinguish the flowofpatients(process)fromtheclinicalworkflow(operation)andanalyze themseparately.This iswhy inFigure 2.2wehaveillustratedhealthcareproductionasanetworkofprocessesandoperations.Theanalysisofhealthcareprocessesexaminestheflowofpatients;theanalysisofhealthcareoperationsexaminestheworkperformedonpatientsbycliniciansandsupportstaff.

Consider a typicalpatientwhomakesavisit toanout-patientclinic:First,thepatientisregisteredatthefrontdeskandthenaskedtowait.Next,amedicalassistantcallsthepatient and escorts him or her to an examination room.The medical assistant may take the patient’s blood pres-sureandaskquestionstomakeaninitialassessmentofthepatient’scondition.Againthepatientisaskedtowaituntilthedoctorisready.Finally,thedoctorinterviewsthepatient

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ProCesses and oPerations of HeaLtHCare

11

andreachesadiagnosis.Afterthis,thepatientreceivessometreatment, let’s say, an injection administered by a nurse.The nurse draws the prescribed medication, cleans thepatient’s injection site, and injects themedication into thepatient’sbloodstream.Thisseriesofchangesinthepatient(from undiagnosed to treated) is the process. The nurse’sactionsoffillingthesyringe,cleaningthepatient’sinjectionsite,andinjectingthemedicationintothepatientcompriseanoperation.

2.3 SUMMARY

Allproductioncarriedoutinanyhealthcaresetting—intheoperatingroom,theclinic, thelab,orthepharmacy—mustbeunderstoodasafunctionalnetworkofprocessandopera-tion.Healthcareprocessestransformunwellpatientsintowellpatients.Healthcareoperations are the clinical actions that

Healthcare servicesInpatient Outpatient

Administrativesupport staff members

Patientswaiting

Patientswaiting

Patientswaiting

Patientswaiting

Transportation

Assessment

Procedure

Doctors, nursesand lab technicians

Medical specialistsand clinical support staff

Healthcare operations

Healthcare

processes

Figure 2.2 the healthcare service production process. (reprinted with permission. J. Michael rona and associates, LLC, doing business as rona Consulting Group and istockphoto LP © 2008–2012, http://www.rona consulting.com; http://istockphoto.com. all rights reserved.)

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accomplish those transformations. These fundamental con-ceptsandtheirrelationshipmustbeunderstoodinordertomakeeffective,evidence-basedimprovementsintheproduc-tionofhealthcareservices.

2.4 REFLECTIONS

Nowthatyouhavecompletedthischapter,take5minutestothinkaboutthesequestionsandwritedownyouranswers:

1.What did you learn from reading this chapter thatstandsoutasbeingparticularlyusefulorinterestingtoyouinhealthcare?

2.Howdoyoufeelabouttheideaof“producing”health-careservicesusingindustrialmethods?

3.Doyouhaveanyquestionsaboutthetopicspresentedinthischapter?Ifso,whatarethey?

4.Are thereanyspecialobstacles inyourmindor themindsofyourcolleagues toapplyingthedistinctionbetweenprocessandoperationinhealthcare?

5.Whatinformationdoyoustillneedtofullyunderstandtheideaspresented?

6.Howcanyougetthisinformation? 7.Whomdoyouneedtoinvolveinthisprocess?

13

Chapter 3

What Is Kaizen?In this book we will be looking closely at the rootsofLeanhealthcareserviceproduction, themeaningofkaizen, and theprocessof conductingakaizenwork-shoporblitz,asitissometimescalled.Fromthestartyoumustrememberthata kaizen workshop will fail unless it is conducted within the framework of a commitment to the philosophy of kaizen itself.First,whatiskaizenandwhyisitsoimportant?

3.1 WHAT IS KAIZEN?

Kaizen means, simply, continuous improvement. InJapanese kai means “to take apart” and zen means“to make good.” Together, these two words mean totakesomethingapartinordertomakeitbetter.Kaizenis based on the fundamentals of scientific analysis inwhichyouanalyze(ortakeapart)theelementsofapro-cess or system to understand how itworks, and thendiscoverhowtoinfluenceorimproveit(makeitbetter).

Leanhealthcareserviceproductionisfoundedontheideaofkaizen.Inpractice,kaizendependsonfastcyclesof learning and application based upon the scientificmethod,intheformoftheDeming Cycle:

◾ Plan:Observeandthendevelopanewvision. ◾ Do:Implementrapidlytotesttheidea. ◾ Check:Checktheresults. ◾ Act:Developawareness;achangeinthinking.

Thesecyclesoflearning,appliedoveralongperiodoftime,adduptoamajorimpactonhealthcareoperationsandresults(seeFigure 3.1).

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3.1.1 Kaizen and Kaikaku

Broadly speaking, kaizen refers to two types of managedchange: kaizen and kaikaku. Technically speaking, kaizenrefers specifically to the continuous, incremental improve-mentofstandardworkonthefrontlineofLeanhealthcareoperations. In broad terms, however, kaizen also refers tokaikaku, themajororradicalchangethat is linkedtoyourorganization’sstrategybymeansofformalproposalscalledA3s (see Figure 3.2). Both types of change are generallyreferredtoaskaizen.

D e fi n i t i o n

plan

doact

check

PDCA

Figure 3.1 the Plan-do-Check-act (PdCa) cycle.

Time

Perfo

rman

ce Im

prov

emen

t

Figure 3.2 Kaizen (continuous improvement) and kaikaku (radical improvement) work in tandem to improve performance over time.

WHat is Kaizen?

15

3.1.2 What Do You Need to Know to Fully Understand How to Do Kaizen?

Themain thing you need to know to begin a continuousimprovement program is how important it is—how thesmallestideascanleadtothegreatestresults.KaizenisthebuildingblockofalltheLeanhealthcareserviceproductionmethodologies; it is the foundation upon which all thesemethodshavebeenbuilt.ThetenprinciplesforimprovementshowninFigure 3.3describethespirityouneedtohaveinordertobesuccessfulinyourkaizenactivities.Thesewillbediscussedthroughoutthebook.

K e y P o i n t

TAKE FIVE

take five minutes to think about these questions and to write down your answers:

1. What continuous improvement activities have you done in your healthcare organization?

2. Can you think of one thing you could change that would improve the way you perform your operation?

Ten Basic Principles for Improvement

1. throw out all of your fixed ideas about how to do things.

2. think of how the new method will work—not how it won’t.

3. don’t accept excuses. Challenge the status quo.

4. don’t seek perfection. a 50-percent implementation rate is fine as long as it’s done on the spot.

5. Correct mistakes the moment they’re found.

6. don’t spend a lot of money on improvements. think: Low cost/no cost.

7. Problems give you a chance to use your brain.

8. ask “Why?” at least five times until you find the ultimate cause.

9. ten people’s ideas are better than one person’s.

10. improvement knows no limits.

Figure 3.3 the right spirit of kaizen.

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3.1.3 How Will Kaizen Change What You Are Doing Now?

Ifyourmedicalcenterhasnotbeendoingcontinuousimprove-ment,thiswillbeabigchangeforyouinmanyways.Youwillneedtimetothinkaboutwhatyoudo,andtimetolearnanddiscoverwaystodowhatyoudobetter.Youwillneedtoolstohelpyourememberyourideas.Inthebeginning,justjottingdownideasoncardsoranotepadthatfitsinyourpocketisallyouwillneed.Askaizengrowsinyourworkplace,youwilllearnmoreandmoremethodstohelpyouunderstandyourwork,theequipmentandinstrumentsyouuse,andtherela-tionshipofyourworktoeveryoneelse’sinthevalue stream.

The value stream is all the activities in your healthcareorganizationthatareneededtoorganizeandproduceatreat-mentorserviceanddeliveritsafelytoyourpatient.Asyoucommittoakaizenapproach,youwillbeadding valueandreducing wasteinthevaluestream.Figure 3.4showsasimplevaluestreammapforahealthcareservice.

3.2 WHAT IS THE PURPOSE OF KAIZEN?

Kaizenactivitiesfocusoneachprocessandeveryoperationinordertoaddvalueandeliminatewaste.Let’stakeaminutetoreviewtheseterms.

3.2.1 Process and Operation

AsdiscussedinChapter2,aprocessisasequenceofcyclesofwork,calledoperations,neededtoproduceanddeliveratreatmentorhealthcareservicetoapatient—totransformapatientfromthestateofunhealthytohealthy.Itincludesthepeople,equipment,supplies,andmethodsused.

An operation is a work cycle defined by a sequence ofspecifictasks.

3.2.2 Value and Value-Added

Value is the worth of a healthcare treatment or service orrelatedproductsuchasmedicinesormedicaldevicesdelivered

D e fi n i t i o n

D e fi n i t i o n

D e fi n i t i o n

WHat is Kaizen?

17

sche

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toapatient.Itisthedegreetowhichapatientrequirement,need,ordesireisfulfilledandmayincludequality,usefulness,functionality,availability,price,attractiveness,andsoon.

Value-addedrefers toanyoperationinahealthcarepro-cess that changes information about the patient, medicalknow-how,medicines,andsuppliesintovalueforthepatient.

3.2.3 Waste

Waste isanyoperationthataddscostortimebutdoesnotaddvalue.ThekeytoLeanhealthcareserviceproductionisthetotaleliminationofwaste.

Therearesevenbasictypesofwastethathavebeenidenti-fiedbythecreatorsoftheToyotaProductionSystem:

1.Overproduction or excess production is producingmore,sooner,orfasterthanthepatientrequires.

2.Waiting isprocess idle timeand timedelaysbeforethenextprocessstepbegins.

3.Transportisunnecessaryormultiplehandlingormove-mentofsupplies,patients,orequipment.

4.Overprocessing or excess processing is unnecessarysteps,workelements,orprocedures.

5.Inventoryorexcess inventoryisproducing,holding,orpurchasingunnecessarysuppliesorequipment.

6.Motionorexcess movementisunnecessaryreaching,walking,orlookingforpatients,instruments,records,orinformation.

7.Defects are rework and correction of errors, qualityproblems,andequipmentproblems.

TheprimarypurposeofkaizenandLeanhealthcareser-viceproduction is toeliminate theseformsofwaste in thehealthcareserviceproductionprocess.

Asyou thinkcarefullyaboutyourownworkandhowtoimproveit,youwillstarttobecomemoreawarethatwhatyoudoimpactswhatothersdo,andwhatothersdoimpactsyou.Atthispoint,yoursupervisorormanagercanbeginsmallgroupcontinuous improvement activities. Continuous improvement

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K e y P o i n t

WHat is Kaizen?

19

teams are the cornerstone of kaizen and Lean healthcare ser-vice production.Inteamsofcliniciansandstaffmembers,youcanhelpeachotheridentifyproblemsinyouroperationsandtheprocessesyouperformtogether.Youcansharewithoneanotherwhatyouneedfromeachotheranddiscoverbetterwaysofworkingtogether.Eventually,youcanparticipateasteamsinkaizenworkshopsorblitzestochangethelayoutofyourworkareaandmakeimprovementsthataffectmorethanjustoneindividualandhisorherworkstation(seeFigure 3.5).

3.3 WHAT IS THE ROLE OF A KAIZEN WORKSHOP?

Oncethecommitmenttokaizenismade,kaizenworkshopsorblitzescanbeheldperiodicallytomakefocusedchanges

TAKE FIVE


1. What operation(s) are you responsible for in your healthcare process?

2. What do you do that is value-added? 3. What is the purpose of kaizen?

Figure 3.5 a kaizen team solving a problem.

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intheworkplacethataffectthewholeteamsimultaneously.Akaizenworkshopmustbecarefullyprepared,wellcoordi-nated,andthoroughlyfollowed-upinordertobesuccessful.Therestofthisbookwilldescribehowtocarryoutasuc-cessfulkaizenworkshop.

3.4 BENEFITS OF KAIZEN AND KAIZEN WORKSHOPS

3.4.1 How Does Kaizen Benefit Your Healthcare Organization?

1.Kaizeneliminatesthehiddencoststhatresultfromtheseventypesofwastethatcanexistinthehealthcareserviceproductionprocess.

2.Kaizen improves the value-added operations in thehealthcareserviceproductionprocesssothattheser-vicedeliveredtothepatientisofthehighestquality,lowestcost,andshortestdeliverytimepossible.

3.Akaizenworkshopallowsmajorchangestobemadeinparticularareasquicklyandwithminimumlossofhealthcareserviceproductiontime.

3.4.2 How Does Kaizen Benefit You?

1.Kaizenhelpsyoueliminatewastedmotionanddelaysinyourwork so thatyoucandowhatyoudobestwitheaseandwithoutannoyinginterruptions.

2.Kaizenprovidesmethodsforyoutothinkaboutwhatyou do and contribute ideas that benefit thewholehealthcareorganization.

3.Akaizenworkshopprovidestheopportunitytoworkwithyourteammatestoimproveyourworkingenviron-menttogether.

3.5 SUMMARY

A kaizen workshop will fail unless it is conducted withintheframeworkofacommitmenttothephilosophyofkaizen

WHat is Kaizen?

21

itself.Kaizenmeans,simply,continuous improvement,andinpracticealsoreferstokaikaku, whichmeanmajor or radical change. Kaizen is based on the fundamentals of scientificanalysisinwhichyouanalyzetheelementsofaprocessorsystemtounderstandhowitworks,andthendiscoverhowtoinfluenceorimproveit.Thesecyclesofchangeareknownas the Deming cycle—Plan-Do-Check-Act. Lean healthcareserviceproduction is foundedon the ideaofkaizen,uponwhichalloftheLeanmethodshavebeenbuilt.

If yourhealthcareorganizationhasnotbeendoing con-tinuous improvement, thiswillbeabig change foryou inmanyways.Youwillneedtimetothinkaboutwhatyoudoandlearnhowtodiscoverways todowhatyoudobetter.Youwillneedtoolstohelpyourememberyourideas.Inthebeginning,justjottingdownideasoncardsoranotepadthatfitsinyourpocketisallyouwillneed.Askaizengrowsinyourworkplace,youwill learnmoreandmoremethodstohelpyouunderstandyourwork,theequipmentandinstru-mentsyouuse,andtherelationshipofyourworktoeveryoneelse’sinthevaluestream.

The value stream is all the activities in your healthcareorganizationthatareneededtoproduceanddeliverahealth-care service to your patient. As you commit to a kaizenapproachyouwill beadding value and reducing waste inthevaluestream.Kaizenactivitiesfocusoneachprocessandeveryoperationinordertoaddvalueandeliminatewaste.A processisasequenceofcyclesofworkneededtoproduceand deliver a treatment or service. It includes the people,equipment, supplies, andmethodsused.Anoperation is awork cycle definedby a sequence of specific tasks.Valueistheworthofatreatmentorservicedeliveredtoapatient.Itisthedegreetowhichapatientneedordesireisfulfilledandmayincludequality,usefulness,functionality,availability,price,attractiveness,andsoon.

Value-addedreferstoanyoperationinaprocessthatchangesinformationaboutthepatient,medicalknow-how,medicines,orsuppliesintovalueforthepatient.Wasteisanyoperationthataddscostortimebutdoesnotaddvalue.ThekeytoLeanhealthcareserviceproductionisthetotaleliminationofwaste.

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Therearesevenbasictypesofwaste:overproduction,waiting,transportation,overprocessing,inventory,motion,anddefects.TheprimarypurposeofkaizenandLeanhealthcareserviceproductionistoeliminatetheseformsofwaste.

Continuous improvement teams are the cornerstone ofkaizenandLeanhealthcareserviceproduction.Inteamsofcliniciansandstaffmembers,youcanidentifyproblemsanddiscoverbetterwaysofworkingtogether.

Oncethecommitmenttokaizenismade,kaizenworkshopsorblitzescanbeheldperiodicallytomakefocusedchangesintheworkplacethataffectthewholeteamsimultaneously.Akaizenworkshopmustbecarefullyprepared,wellcoordi-nated,andthoroughlyfollowed-upinordertobesuccessful.

3.6 REFLECTIONS

Nowthatyouhavecompletedthischapter,takefiveminutestothinkaboutthesequestionsandtowritedownyouranswers:

◾ What did you learn from reading this chapter thatstandsoutasparticularlyusefulorinteresting?

◾ Doyouhaveanyquestionsaboutthetopicspresentedinthischapter?Ifso,whatarethey?

◾ What additional information do you need to fullyunderstandtheideaspresentedinthischapter?

23

Chapter 4

What Is a Kaizen Workshop and What Are the Key Roles

for Success?In the previous chapterwe discussed themeaning ofkaizenandtheimportanceofanongoingcommitmenttocontinuousimprovementinthemedicalcenterbeforeimplementingakaizenworkshop.Inthischapterwewilldefine a kaizen workshop, describe some things youshould be aware of before starting, identify the rolespeople need to play for a successful workshop, andintroducethethreephasesofakaizenworkshop.

4.1 WHAT IS A KAIZEN WORKSHOP?

Akaizen workshop isateamactivityaimedatrapiduseofLeanmethodstoeliminatewasteinparticularareasof the healthcare organization. It is well-planned andhighlystructuredtoenablequick,focuseddiscoveryofrootcausesandimplementationofsolutions.

Beforetheworkshoptakesplace,anareaisselectedandprepared,aproblemischosen,abaselineisdeter-mined, and an improvement target andmeasurementsare established. Leaders and teams are selected andtrained,andatimeframefortheworkshopisset.

Kaizenworkshopstypicallylastfivedays,sometimesincludinglatenightsorearlymornings,althoughmanysuccessfulkaizenactivitiesareplannedforshorterperi-ods—fromahalfdaytothreedays.Theseshorterinitia-tives,referredtoaskaizen events,focusmorenarrowly

D e fi n i t i o n


D e fi n i t i o n

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andrequirelessplanning;theyusuallyworkwellafterlongerkaizenworkshopshaveachievedmajorbreakthroughsintheselected areas, making the identification of more focusedproblem-solvingareaspossible.

Every kaizen workshop is chartered by an A3T, a teamcharter(printedonlarge-formatpaper)thatlinkstheactivityclearlytoasignificantproblemandestablishesdefinitetargetsandmilestones(seeFigure 4.1).

4.2 HOW IS A PROBLEM SELECTED?

Once a value stream map has been completed, major problems or opportunities for improvement within the value stream can be identified.Akaizenworkshopfocusesononeormoreoftheseopportunities.Problemschosen forkaizenshouldbeonesthatcausesignificantpaintotheorganization,butcanalsobeaddressedsuccessfullyinafive-dayworkshopwithfollow-upactivities.

Technically,kaizenworkshopsare reallykaikakuevents.InmatureLeanenterprises,theneedforkaizenworkshopsis determined in tandem with strategic planning, or whenmajor,unanticipatedproblemsoccur.

Kaizen workshops can focus simply on starting 5S(a methodforcreatingaclutter-freeandorganizedworkplace)orcreatingstandardworkinoneworkarea,orothergoalslimited to reducingwaste in a single areaoroperation;ortheycanfocusonrearrangingthelayoutofanentireprocess.Themorechallengingorwidespreadthekaizenworkshop’sfocus,themoreplanningandcommunicationwillbeneededforittosucceed.

4.3 CAUTIONS

Kaizen should be done without spending new money, adding new full-time employees, or adding new equipment.Kaizenactivity focuses on testing small changes that can have animmediate impact on access to care, patient safety, andemployeesatisfaction.Requeststospendlargesumsofmoneyoften take months for healthcare organizations to process!

D e fi n i t i o n

K e y P o i n t

K e y P o i n t

Kaizen WorKsHoPs and KeY roLes for sUCCess

25

Kaizenisaboutchangingthewaywethinkaboutourworktoday so that we can do it better tomorrow. Besides, thedisarminglysimplesolutionsdiscoveredduringfivedaysofakaizenworkshopfrequentlymakeaddingnewpeopleortechnologycompletelyunnecessary.

ThereareseveralotherissuestobeawareofinusingkaizenworkshopstoimplementLeanhealthcareserviceproduction.

4.3.1 Plan in Advance for Coverage

Be sure that you have adequate staff and equipment to cover the reductions that will occur during the workshop.Healthcareserviceproductionoutputcanbeaffectedduringaworkshopascliniciansandstaffmembersdirecttheirtimetoworkshopactivities.Sometimesstoppagesarerequiredtomakesignifi-cantchangesintheprocessorlayout.Youwillalsohavetoretraincliniciansandstaffmembersinnewprocessesastheseprocesses become established. Planning for this slowdownwill ensure that overall healthcare service does not sufferwhileimprovementsbecomethenewoperationstandards.

4.3.2 Put the Focus on Clinician and Staff Member Participation

Be sure, if outside consultants are used, that they do not impose their ideas on clinicians and staff but rather involve the team in creating solutions.Remember,thepeoplewhoknowthemostabouthowtoimprovethejobaretheoneswhodoiteveryday.Employeetrainingisanothernecessity.Forclini-ciansandstaffmemberstosucceedinthenewmethods,andunderstandhowto thinkabout their jobsusingLeanprin-ciples,theyneedtolearnwhatthesemethodsandprinciplesare.It isnotenoughthat thepersonleadingtheworkshopunderstandsthem.Everyoneinvolvedmustbetrained.

ParkNicolletHealthServicesprovideshealthcareservicesto millions of people in the Minneapolis, Minnesota areaand isapioneerinLeanhealthcaremanagement.Thestory

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K e y P o i n t

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27

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ofParkNicolletprovidesagoodexampleofhowbesttousekaizenworkshops.

Before theadoptionofLeanhealthcareandkaizen,whenthemedicalcenterwasincrisisastheresultofamedicalerrororsentinelevent,theycreatedateamofinternalconsultantstochangethemedicalcenterusingavarietyofpromisingbutpiecemeal approaches to healthcare safety and quality. Thequalitydepartment andParkNicollet’s leadersdecidedwhatwastobedoneandimposednewstandardsoncliniciansandstaffmembers,oftentocomplywithexplicitdemandsfromtheCenterforMedicareandMedicaidServices(CMS)ortheJointCommission,ParkNicollet’sdeemingagency.Therewaslittlepreparation before the workshops and almost no follow-upafter them.WhileCMS and the Joint Commissionmight besatisfiedintheshorttermwiththeactionstaken,inthelongtermthechangesdidnotlastandthemedicalcenterwasleftingreaterchaosthanbefore(seeFigure 4.2).Inadditiontotheoriginalproblems,theynowhadaproblemwithmorale.

Inanattempttobecomemoresystematicinitsapproachtochange,ParkNicolletbroughtinexperiencedexternalquality

Figure 4.2 the kaizen blitz: Who is it for? (reprinted with permis-sion, J. Michael rona and associates, LLC, and istockphoto LP. © 2008–2012, http://www.ronaconsulting.com and, http://istockphoto.com; all rights reserved)


29

consultantswhohelpeddeterminetherightproblemsonwhichto focus in a series of major improvement initiatives. Largenumbersofinternalconsultantsweretrainedinproblemsolv-ingandadvancedstatisticalmethodsandthenputinchargeofcollectingandanalyzingquantitativedataandgettingresults.Theemphasiswasoftenplacedfirstonfinancialimprovement,not patient safety or quality.While the approachwas intel-lectuallyrigorous,itdependedprincipallyuponexperts,andoftenignoredtheknow-how,observations,andstoriesofcli-nicians and staff on the front line of healthcare operations.Employeesstillfeltthatthenewprocessesandstandardswerebeingimposedonthemfromoutside,whichtheywere.

The medical center shifted its improvement policy away from the expert-driven, project-based approach that imposed changes on clinicians and staff members by creating a Kaizen Promotion Office staffed by internal consultants trained in Lean healthcare and kaizen. TheKaizen PromotionOffice(KPO)wasaninternallyledsystemfortrainingandempower-ingcliniciansandstaffmemberstomakechangesthemselves.Park Nicollet recognized the need for outside help fromexpertswhounderstoodLeanhealthcareserviceproductionmethodsandhowto implement them,butnowtheexper-tiseofpeopleon themedicalcenterfloorcouldno longerbe ignored.Many of the ideas that had been imposed onthecliniciansandstaffmembersbythequalitydepartmentandexternalconsultantswereideasthecliniciansandstaffmembers had already asked leadership to implement longbefore.Cliniciansandstaffjustneededtheopportunitytodowhattheyknewshouldbedoneallalong,butnotbyhavingideasstuffeddowntheirthroatswithoutpreparation,andinacookie-cutterapproachthatdidnottakeintoaccountthemanydifferentsituationsandpeopledoingthework.

As you shift to Lean healthcare service production, it isessentialthatyoudosowiththepeople,nottothepeople.Theresultswillbemuchmorecomplete,theywilllastmuchlonger, and improvementswill continue to evolve becauseeveryonedoingtheworkwillbetrainedandempoweredtothinkbetterabouttheirwork.

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4.3.3 Understand the Importance of Preparation and Follow-Up

Inaddition toplanning forcoverageandputting the focusonclinicianandstaffmemberparticipation,preparationandfollow-up are the other cornerstones of successful kaizenworkshops. You may find that preparation and follow-uprequiremoretimethanconductingtheworkshopitself.Thisbookprovidestoolsforthepreparationandfollow-upstages.Also,theAppendixrefersyoutobooksthatexplaintheLeantrainingprogramsyouneedtoputinplacetoachieveLeanhealthcareserviceproductionwithkaizenworkshops.

AtamajormedicalcenterinthePacificNorthwest,trainingtopmanagersandmakingsurethatkaizeneffortsweresup-portedforthelongtermfromthetopwasthefirstimportantsteptheorganizationtookafterkaizenworkshopsfailedtoproduce theneeded results.At thispoint,everyoneunder-stoodthatthewholeinfrastructurehadtosupporttheshifttoLeanandthattheeffortmustbesystemwideandendur-ing,not justsomethingimposedduringaweeklongkaizenworkshop.This is themost criticalpoint toknow—kaizen workshops will only succeed when done within the context of an existing culture that supports continuous improvement.

4.4 SUCCESSFUL KAIZEN IN ACTION

Figure 4.3showsthebeforeandafterofhowaseriesofkaizenworkshops,facilitatedbyahealthcareorganization’sKPOandledbycertifiedworkshopleadersandteamleaders,improvedclinical flow in the organization’s outpatient clinics. Prior tokaizen,theclinicalflowwasfullofwastedmotionandconstantinterruptions.Nursesandmedicalassistantswalkedrepeatedlytoandfromthesupplyroomfornecessarysupplies.Intheiroffices,doctorsweresometimesunawarethatpatientshadbeenroomedandwerewaiting to see them.Despite the fact thatappointmentswerescheduled,theredidnotseemtobeaclearwaytoprioritizethework.Asaresultofalloftheseinterrup-tions,inefficiencies,anddelays,doctorsfrequentlystayedlatetochartandtorespondtoamultitudeofrequests,forexample,

E x a m p l e

K e y P o i n t

E x a m p l e


31

fromthelabandpharmacy.Doctorsrarelyreturnedhomefordinner,whichwasakeydissatisfier fordoctors,nurses, andstaffalike.Notsurprisingly,theseclinicswerelosingmoney.

Duringafive-dayworkshop,thekaizenteamdecidedtotrysomethingnew.Adoctorandamedicalassistantwouldformateamresponsibleforseeingpatientsintwocontiguousrooms,orahealthcare production cell.Thiswouldminimizethemotionwasteofwalking,amongotherthings.Whilethedoctorsawonepatient,themedicalassistantwoulddischargethepreviouspatientandroomthenext.Afterrooming,themedicalassistant“leveled”thedoctor’sworkbyprioritizing

Doctors chart,review labs, and

return callspast closing

Figure 4.3 Clinical flow before and after kaizen.

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the doctor’s phone calls, charting, and requests from thelabandpharmacyandplacedthenecessarypaperworkaskanban,orsignals,inaflow station.Theflowstation,placedstrategically between the two rooms, minimized walking,butmainlywasused to remind thedoctor thatheor shehad important work to do. By adopting the concepts ofU-shapedproductioncellsandleveling,theorganizationwasabletoseepatientsaccordingtotakt time(therateofpatientdemand).Asaresultofcreatingthiscompactflowandcare-fullyorganizingallofthedoctors’work,patientswereseenpromptly,anddoctorsnormallycompletedeverythingbeforetheclinic’snormalclosinghoursandgothomeintimefordinner.Inaddition,theclinicsbegantoturnaprofit.

Thisgroundbreakinghealthcareredesignisstillsustainedtodayandhasspreadtootherhealthcareorganizations.Butitcouldnothavebeensustainedorfaithfullyreplicatedwithanexpert-drivenproject-based approach to improvement. It istheresultofLeanconceptsandtoolsappliedinthefive-daykaizenworkshopformatdescribedinthisbook,activelysup-portedbyseniorleaderswhothemselveshavebeencertifiedasworkshopleaders.

4.5 WHAT ARE THE KEY ROLES FOR A SUCCESSFUL KAIZEN WORKSHOP?

Therearefivemajorrolesinakaizenteam(seeFigure 4.4):

1.Sponsor 2.Processowner 3.Workshopleader 4.Teamleader 5.Teammember

There are a number of important things to consider indeterminingthepeoplewhowillbeinvolvedinmakingyourkaizenworkshop a success.Of course, the teammembersandteamleaderaretheprimaryparticipants.Detailsontheirrolesandhowtoselectthemwillbediscussedinthenextchapter.Buttherearemanyotherswhoseroleswillprovide


33

thebackupandfollow-throughthattheteamwillneedbefore,during,andaftertheworkshopsothattheireffortstakeholdandbringmeasurableandlastingresults.Inadditiontothefivemajor roles,unionsalsoprovide importantsupport forkaizen.EveryoneinvolvedwillneedagenuinecommitmenttoLeanhealthcaretomakethekaizenworkshopreturnopti-malimprovementstothemedicalcenter.

4.5.1 Workshop Leader

The workshop leader is the highest-ranking person in the actual workshop, and the primary link (along with the team leader) between top management and the team.Theworkshopleadermakes decisions, assignments, justifies expenditures, andcoordinatesallbehind-the-scenesactivitiesnothandledbytheteamleader.Heorsheworkswithallthekeyplayersintheplanningandfollow-upphasestomakesuretheneededcom-municationoccurs.Heorsheshouldalsosupporttheprocess

K e y P o i n t

TAKE FIVE


1. What are three important things to be concerned about before deciding to lead a kaizen workshop?

2. Where do you think you should do your first kaizen workshop and what do you think the focus should be?

sponsor

teammember

teamleader

workshopleader

processowner

Roles and responsibilities

Figure 4.4 the five major roles on a kaizen team.

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owner inpreparing for theworkshop, and the team leaderthroughouttheimplementation(seeFigure 4.5).

Ifyouarejuststartingoutandhaveneverdoneakaizenworkshopbefore, youmaywant touse anoutsideprofes-sionaltoleadyouthroughthefirstonesyoudo.Thisbookisintendedtoprovideyouwithmanyofthedetailsinvolvedinplanning,preparing,andconductingakaizenworkshop,butonceinthethickofit,youmaybegladfortheexpertiseofsomeonewhohasbeentherebefore.Aconsultant’sprimarypurposeshouldbetoeducateyouinLeanconceptsandtoolsandthentohelpyoubecomeskilledinrunningthesework-shopssothatyoucandoitonyourownafterafewexpe-riences, and so that you can begin to train others to leadkaizenworkshops.Unlessanorganizationisdoingitforitselfand solutions are coming fromwithin (not being imposedfromwithout)thechangesmadeinakaizenworkshopwillnotlastnorbearlong-termbottom-lineresults.

Whether the workshop leader is an outside consultant or other key figure in your medical center, knowledge of kaizen

K e y P o i n t

Coach

Diplomat

CommunicatorReferee

ProgressMonitor

SafetyMonitor

Figure 4.5 the workshop leader is a ViP with many responsibilities. (reprinted with permission, J. Michael rona and associates, LLC and istockphoto LP. © 2008–2012, http://www.ronaconsulting.com and http://istockphoto.com; all rights reserved)


35

workshops and experience coordinating them is essential. If trainedinLeanconceptsandtoolsandexperiencedwithkaizenworkshops,sometimestheprocessownerisassignedtheroleofworkshopleader.

4.5.2 Sponsor

The sponsor decides to initiate kaizen in the medical center. (If thedecisionismadebyanexecutiveteam,onepersonshouldbechosentofunctionasthesponsor.)Thesponsorwillchoosetheworkshopleader(orconsultant).Oncekaizenisinitiated,thesponsorwillneedtofullysupporttheworkshopleaderinalltheireffortstomovetowardLeanhealthcareserviceproduction.

Kaizen is about eliminating waste in healthcare pro-cesses, not about eliminating people. Toyotasucceededwithitsproductionmethodsbecauseeliminatingwasteledthemtoaddproductionlinesandincreasecapacity.Inthisway,in a very short time they dominatedworldmarketswithinnovativeanddefect-freeproducts.Theydidnoteliminateworkers;theyeliminatedcostsduetowaste.

One very important role of the sponsor is to make it clear throughout the healthcare organization that successfully implementing kaizen workshops and Lean processes will not endanger anyone’s job.Peoplemaybereassigned,theymaybecomekaizenteamleadersandtrainotherstoleadkaizenworkshops,ortheymaymovetootherworkareas.Additionaltrainingwill beneeded for everyonewhen standardworkandLeanhealthcareoperationsare fully inplace,and thiswill also ensure clinicians’ and staff members’ long-termvaluetothehealthcareorganization.Everyteammemberwillbecomemoreinvolvedandempoweredinimprovinghisorherown operations.

4.5.3 The Union Role

Unionsmayrepresentsomestaffmembers,andfromthestart,needtobepartners in thehealthcareorganizationpolicy toimplement Lean healthcare service production. Provisionsshouldbeaddedtounioncontractstoallowfortotaladoptionof

K e y P o i n t

K e y P o i n t

K e y P o i n t

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themethodsoftheLeanhealthcareserviceproductionsystem,andthispartnershipshouldbecommunicatedthroughoutthemedicalcenter.Unionleadersshouldbeincludedintheplan-ningstagessothattheywillunderstandandsupportclinicianorstaffmemberparticipationinthekaizenworkshop.

4.5.4 Process Owner

The process owner, usually the department manager, works with the workshop leader (if not assigned the role of workshop leader) and participates in the planning and preparation stages:tochooseanappropriateareaonwhichtofocustheworkshop,toselectaproblemforimprovement,toidentifyteamleaders,andtoguideandapprovetargetsandmeasures.Neithertheworkshopleadernortheprocessownershoulddecidewhatthesolutionstothetargetedproblemsare.Thisisthepurposeofhavingtheworkshopandistheroleoftheteam.Thepeoplewhodothejobarethebestonestoiden-tifyhow it canbe improved.However, the teammemberswill appreciate the training and guidanceprovided by theprocessownertohelpensuretheirsuccess,andwillappreci-atetheclearunderstandingthattheprocessownerandhisor her superiors are fully supportive of theprinciples andmethodsofLeanhealthcareserviceproduction.Theprocessowner’sprimaryroleistocommunicatewholeheartedsup-portforthekaizenteams.Knowingthatthewholehealthcareorganization isbehindyouenablesyou toputyourwholeattentionandbestthinkingintoakaizenworkshop.

K e y P o i n t

TAKE FIVE


1. What is the role of the sponsor in a kaizen workshop? 2. does your top management support Lean healthcare

service production? How? 3. How does the union participate in Lean healthcare

service production activities in your medical center?


37

4.6 COMMUNICATING TO THE WHOLE HEALTHCARE ORGANIZATION

ABOUT THE KAIZEN WORKSHOP

Thorough communication will make all the difference inwhetheryourworkshopsucceedsordoesnot.Anannounce-mentfromthetopwillcommunicateserioussupportfortheactivity.Postingthescheduleandaclarificationofthestepswillhelpeveryonebecomefamiliarwithwhattoexpectandwillreducefearsabouttheunknown.Dailycommunicationaboutworkshopprogresswillalloweveryonetobeinformedandfeelincluded,eveniftheyarenotpartoftheteam.Thiswillhelppreparethemforwhentheywillbeinvolvedandwillremoveanysenseofbeingleftoutofsomethingimpor-tant.Publishdetailsassoonastheyareknown.Postlistsoftrainingsessionsandwhohascompletedthem.

Asktheuniontohelpcommunicatethedetailstoensurethatthisisateameffort.Circulateandpostdescriptionsofwhatwillhappenduringthekaizenworkshopandtheover-allplanforworkshopsthatwillincludeeveryoneovertime.Leteveryoneknow theareas thatwillbeaffectedand thebenefits tobe expected. Showbefore and afterphotos.Athealthcareorganizationmeetings,presentvideooftheareasbefore and after the workshops. Publish photos in health-careorganizationnewsletters.Supportdepartments,suchasthemaintenanceteam,willbeimportantalliesinworkshopsinmanyways, including helping youmove and reconnectequipment and providing advice about improving bottle-necks.Theyshouldbeincludedinallmemosandcommu-nicationsandinvitedtoallpresentationswheretheycanbethankedpubliclyfortheirhelp.

Communication does not stop with the workshop itself.Theformal presentation at the end of theworkshop should bepublished,andfollow-upstepsshouldbecontinuallypostedasassignmentsarecompleted.Electronicmechanismsandphysi-calbulletinboardsshoulddisplayongoingresultsandfutureplans.Communicationandvisualdisplayofkaizeneffortsareimportant aspects of the Lean environment and should be




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keptupdatedwithnewinformationsothattheybecomecom-monfocalpointsforeveryoneinthehealthcareorganization.It shouldbecommonpracticeforpeopletocheckthebulletinboards for new information and to look forward tohavingtheirownpictureorresultspostedoneday.

4.7 THREE PHASES OF A KAIZEN WORKSHOP

Therearethreeprimaryphasesofakaizenworkshop,whichwillbethesubjectoftherestofthisbook.

1.Phase one:Planningandpreparation 2.Phase two:Implementation—theworkshopitself 3.Phase three:Presentationandfollow-up

4.8 SUMMARY

Akaizen workshop isateamactivityaimedatrapiduseofLean methods to eliminate healthcare service productionwasteinparticularareasofthehealthcareorganization.Itiswell-plannedandhighlystructuredtoenablequick,focuseddiscovery of root causes and implementation of solutions.Before the workshop takes place, an area is selected andprepared,aproblemischosen,abaselineisdetermined,andan improvement target and measurements are established.Leadersandteamsareselectedandtrained,andaschedule

TAKE FIVE


1. Why is communication so important to the success of a kaizen workshop?

2. do you have a healthcare organization newsletter? is it daily, weekly, or monthly?

3. Where is new information about goings-on at the medical center posted in your area?

4. What would you like to know more about in your medical center?


39

is set. Workshops typically last one week, although manysuccessfulkaizeninitiativesareplannedforshorterperiods.These shorter kaizen events focusmorenarrowly and lessplanningisrequired.

KaizenworkshopsarecharteredusinganA3T team charter thatlinkstheworkshoptoasignificantproblemandestablishestargetsandmilestones.Problemsareusuallyidentifiedafteravaluestreammaphasbeencompleted.Aworkshopmightfocusonstarting5Sorcreatingstandardworkinasinglearea,oronrearrangingthelayoutofanentireprocess.Themorechalleng-ingorwidespreadthekaizenworkshop’sfocus,themoreplan-ningandcommunicationwillbeneededforittosucceed.

Be sure that you have adequate staff and equipment tocover the reductions thatwill occur during theworkshop.If outside consultants are used, be sure that they do notimposetheirideasoncliniciansandstaffmembers,butratherinvolvetheteamincreatingthesolutions.Thepeoplewhoknowthemostabouthowtoimprovethejobaretheoneswhodoiteveryday.Employeetrainingisanothernecessity.Itisnotenoughthatsomeoneleadingtheworkshopunder-standsthemethods;everyoneinvolvedmustbetrained.

There are a number of important things to consider indeterminingthepeoplewhowillbeinvolvedinmakingyourkaizen workshop a success. The team members and teamleader are the primary participants, but others, includingtheworkshop leader, sponsor, andprocessowner,providesupportbefore,during,andaftertheworkshopsothattheireffortstakeholdandbringmeasurableandlastingresults.

Whether theworkshop leader isanoutsideconsultantorotherkeyfigureinyourmedicalcenter,knowledgeofkaizenworkshops and experience coordinating them is essential.The workshop leader is the highest-ranking person in theworkshop and the primary link between topmanagementandtheteam.

Kaizenisabouteliminatingwasteinhealthcareprocesses,notabouteliminatingpeople.Oneveryimportantroleofthesponsor istomakeitclearthroughoutthehealthcareorgani-zationthatsuccessfullyimplementingkaizenworkshopsandLeanprocesseswillnotendangeranyone’sjob.Peoplemay

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be reassigned, they may become kaizen team leaders andtrainothers,ortheymaymovetootherareas.

Unions represent the clinicians and staff members and,fromthestart,needtobepartnersinthehealthcareorganiza-tionpolicytoimplementLeanhealthcareserviceproduction.Union leaders shouldbeincludedintheplanningstagessothattheywillunderstandandsupportemployeeparticipationinthekaizenworkshop.

Theprocessowner(ifnotassignedtheroleofworkshopleader)workswiththeworkshopleaderandparticipatesinthe planning and preparation stages: to choose an appro-priate area on which to focus the workshops, to select aproblem for improvement, to identify team leaders, and toguideandapprovetargetsandmeasures.Theprocessowner’sprimaryroleistocommunicatewholeheartedsupportforthekaizen teams.

Thorough communication will make the difference inwhetheryourworkshopsucceedsordoesnot, and itdoesnotstopwiththeworkshopitself.CommunicationandvisualdisplaysofkaizeneffortsareimportantaspectsoftheLeanenvironment. Displays should be kept updated with newinformation so that they become common focal points foreveryoneinthehealthcareorganization.

There are three primary phases of a kaizen workshop:planning and preparation; implementation—the workshopitself;andthepresentationandfollow-up.

4.9 REFLECTIONS





41

Chapter 5

Phase OnePlan and Prepare

Inthelastchapter,theimportanceofthoroughprepara-tionwas emphasized. This chapter leads you throughthekeystepsofpreparingforakaizenworkshop.Thesponsor will have given guidelines to the workshopleader as to the focus of the workshops, specific tar-gets for process improvement, and so on. SupportedbyexternalconsultantsorperhapsinternalconsultantsfromaKaizenPromotionOffice, theworkshop leaderwillbetheSenseiandtechnicalconsultanttothekaizenworkshop team.Heor she is responsible for all threephases of the kaizen activity, including preworkshopdata collection, running theworkshop, and successfulfollow-upoveraperiodof90days.

Theprocessofplanningakaizenworkshopnormallybegins by identifying a particular value stream thatneeds improvement.Theworkshopleaderworkswiththeprocessownertopreparethevaluestreamfortheworkshopandhelpsetgoals.Theworkshopleaderandthe process owner, dividing responsibilities as appro-priate,scheduletheworkshop,selecttheareaandtheproblemforimprovement,andchoosetheteamleader(or leaders, if the workshop will include more thanone area).

5.1 SELECT AN AREA

Thefirststepistochoosewhereyouwillconductyourfirstkaizenworkshop.Prior to theworkshop,youwillnormallymapvaluestreamsofinteresttoidentifyimpor-tant areas thatwill become the focalpointsofkaizen


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activity.Kaizenactivityaddressesproblems in the work;thatis,problemswithstandardworkorthelackofstandardwork.Thesearethecausesofproblemsthatresultinpoorperfor-mancewith respect toquality, safety, cost, anddeliveryofhealthcareservicestopatients.

Youwillwanttochooseanareathatwillhaveanimpactbut not pose too many difficult problems to solve in thebeginning. Each workshop will teach you things that willmakethenextonesmootherandeasiertorunsuccessfully.Also,eachworkshopprovidesatraininggroundfornewteamleaders.Aspeoplegainexperience in runningworkshops,and as measurable results accumulate in the areas whereworkshopshavebeenrun,itwillbecomepossibletotacklemorecomplexareasanddifficultproblems.Startslowlyandbuild momentum as you gain confidence and experience.Youwillgetbettereachtimeyourunaworkshopandsowillyourteams.

Youcanchooseseveralareaswhereyouwouldliketostartandcompare themeritsofeach.Thiswillensure thatyoustartwith thebestonefirst, basedon several criteria, andhelpyoudeterminewhatwillbenext.EachkaizenworkshopshouldbechoseninordertocreateaprogressionofresultsthatsupportimplementationofLeanmethodsthroughoutthemedical center. There are a number of things to considerasyoumakeyourchoices.Use theKaizen Workshop Area Selection Matrix (Figure 5.1)tohelpyoucomparecriteriaofdifferentareas.

Inordertohaveabigimpactrightaway,chooseanareawithoneormoreofthesecharacteristics:

◾ Itisdelugedwithworkinprocess(WIP).(Forexample,in the hospital or clinic, WIP inventory consists ofpatientsintheprocess.Inthelab,inventoryconsistsoflabsamples.)

◾ Ithasactivitiesthatoccuralloverthemedicalcenter.◾ Ithasasignificantbottleneckorothermajorhindrancetotheflowofhealthcareservices.

◾ Itisanareawhereeverythingisamess.

N e w T o o l

PHase one

43

Kaizen Workshop Area Selection Matrix

Criteria Area A Area B Area C Area D

Many patients waiting

activities occur all over the clinic or hospital

Process bottleneck (e.g., long process setup times)

frequent interruptions to clinical processes

everything is a mess

Medium to high patient demand or census

no more than 12 clinicians or staff members

Complete, not a partial process

Multiple operations required to serve the patient

the process is visible, robust (i.e., can deal with change)

Process can be copied in other clinical operations or areas

significant market or financial impact

operational problems (not management issues) to resolve

Clinicians and staff want a kaizen workshop

Clinicians and staff have been exposed to kaizen

Most clinicians and staff are familiar with the area

Figure 5.1 a Kaizen Workshop area selection Matrix.

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Donotstartwithhighlycomplexareasservingawidemixofpatientneeds;instead,selectanarea

◾ thathasmediumtohighvolume,◾ that involves aworkgroupofnomore than twelvecliniciansandstaffmembers,

◾ thatisacompleteandnotapartialprocess,and◾ that requires four to six processes to complete theservice.

Theareashouldhaveaprocess

◾ thatisvisible,◾ thatisrobust,◾ thatcanbecopiedinotherareas,◾ thathassignificantpatientorfinancialimpact,and◾ that has operational problems, not management orpolicyissuestoresolve.

Chooseanarea

◾ wheremostof theclinicians and staffmembers arereadyandwillingtomakechanges,

◾ wherecliniciansandstaffmembershavealreadybeencross-trainedorhavebeenexposedtokaizenwork-shopsbefore,and

◾ whichmostoftheemployeesarefamiliarwith.

TAKE FIVE


1. What are five criteria for selecting an area in which to do a kaizen workshop?

2. What are three areas in your medical center that would make good kaizen starting points? Based on the Kaizen Workshop area selection Matrix, which of these three areas should be first and why?

PHase one

45

5.2 SELECT A PROBLEM FOR IMPROVEMENT

Oncetheareahasbeenselected,thefocusforthekaizenwork-shopmustbedecided.Besurethatyouclarifytheboundariesofthechosenarea,usingtheA3Tchartertospecifythestartandendpointsoftheprocessanditsspecificcustomersandsuppliers.Theseboundariesmustbemaintainedthroughoutthekaizenworkshop.Talk to thepeoplewhowork in theselectedareaabouttheprojectandworkwiththemindecid-ingontheproblemtobeimprovedintheworkshop.

The reasons you chose this particular area for a kaizenworkshopprobablyincludedsomeunderstandingofwhatisneededinthisarea.Nowitistimetocheckyourassumptionsandexaminetheconditionsandtheprocessusedinthisareamoreclosely.Inselectingafocusforthekaizenworkshop,severalthingsneedtobeconsidered.Has5Sbeenconductedthere?Shouldthatbethefocusofthefirstworkshopinthisareaordoyouwanttoimplement5Smoregraduallybeforeconductingtheworkshop?

Thecomplexityinvolvedandthelengthoftimeneededtoprepareforyourkaizenworkshopdependsontheproblemyouchoose to improveor the implementationyouwish tolead.Thesealsodeterminethelengthoftheworkshopitself.

5.2.1 Elimination of Waste as an Overall Focus

InChapter3,wastewasdefinedasanyoperationthataddscost or time but does not add value. Eliminating waste isthepurposeandfunctionofLeanhealthcareserviceproduc-tion.Thefocusofakaizenworkshopmustbechosenforitsimpactonthewasteintheselectedarea.Beginbyexaminingthecurrentstateoftheprocessinthechosenarea.Analyzetheprocessforthewastethatexiststhere.

Youmayremembertheseventypesofwaste(seeChapter 2,Figure 2.1).The first challenge of kaizen is to understand how to identify waste.Agoodplacetostartiswithwastedmotion.Begintoexaminetheworkyoudo,theoperationsyouareresponsiblefor,andtheworkareawhereyouprovidevalueto the patient.What gets in theway of doing yourwork?


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Whendoyoufindyourselfmoving tofind somethingyouneedinordertodoyourwork?Howoftendoyouhavetolookforaninstrument?

Thesequestionsandotherslikethemarethestartofidentify-ingwaste—lookingatyourownworkandworkplaceforwaste.Thenyoucanconsiderhowyourworkaffectsothersandhowothers’workaffectsyou.Begin toaskyourself thesekindsofquestionsandyouwillgetanideaofhowkaizenworks.

Firstyouexaminewhat is;youpaycloseattentiontowhatyoudothatisvalue-addedandwhatyoudothatisnot.FiveKeyStepsforDiscoveringWaste(Figure 5.2),showsyouwhichques-tionstoasktobeginidentifyingwaste.Look,withoutassump-tions,attheareaandtheprocesstoseewhatisreallygoingon.

N e w T o o l

Figure 5.2 five key steps for discovering waste.

PHase one

47

Ask:“Whatisthepurpose?”and“Whyisthisnecessary?”etc.Recognizewhatisnotworkinsupportoftheprimaryfunctionoftheprocess.Ask“why”fivetimesabouteachwastefulpartoftheoperation:“Whydoesthisoccur?”“Whyisthisnecessary?”Thiswillleadyoutotherootcauseoftheproblemandthefocusoftheimprovementyouneedtomake.

Once the causes of problems are understood, you canexperimentwithways to eliminate the things you do thatarenotvalue-added.Problem solving is the heart of kaizen. It begins with one idea, and it never ends.

Ifyouhavetolookforaninstrumentoverandoveragain,considerwhy.Whydoes itdisappear?Wheredoyouput itwhenyouarefinishedusingit?Whoelseusesit?Wheredoyouwant it tobe?Whendoyouneedit tobethere?Howcanyoumakethishappen?Thistypeofproblemandthesequestionsand the solutions thatwill emergeasyoucreateideasarepartofthekaizenapproachcalled5S.Perhapsyouhavealreadydonethisinyourhealthcareorganization.Ifnot,a kaizenworkshopcanbeheldtoget5Sstarted.

Areyourprocesseschaoticorconfusingsothatcliniciansandsupportstaff—despitetheirhardworkanddiligence—arepronetoinadvertenterrors?Thisisalltoofrequentlythecaseinhealthcare.Forthisreason,youmaywanttomakeimple-mentingstandardworkthefocusofyourkaizenworkshop.

Ifyoufindthatlengthysetuptimesforyourclinicalpro-cesses or equipment causeproblems, or if younotice that

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TAKE FIVE


1. What are three types of waste in the operation(s) you are responsible for?

2. What are three types of waste that currently exist in your broader healthcare service department or area?

3. Can you think of one improvement idea for each waste you have identified that you would like to share with your coworkers?

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youarecontinuallymovingpatientsforeachsetupyoumustmake, you can consider learning more about quick setuptechniques.Butevenbeforeyouadvancetothesemethodsyoucandoalotonyourownjustbythinkingabouthowtoimproveyouroperationbyeliminatingunnecessarymotions.

5.3 SPECIAL CONSIDERATIONS IN CHOOSING A PROBLEM FOR IMPROVEMENT

Continuousflow,mistake-proofing,andkanbanareadvancedmethodsof Leanhealthcare serviceproduction.Theyhavegrown from the simple beginning of identifying waste inorder to eliminate overproduction, excess inventory, andunnecessary transport from value-added operations andprocesses. Kaizen workshops can focus on implementingtheseadvancedtechniques,andtheyareoftenusedforthispurpose,butit iswisetoimplementsimplerapproachestoidentifyingandeliminatingwastefirst.Herearefourspecialconsiderations related to the focusof thekaizenworkshopthatyouchoose:

1.Implementing5S 2.Implementingstandardwork 3.Eliminatingbottlenecksorimprovingsetuptimes 4.Implementing continuous flow, mistake-proofing, or

kanban

5.3.1 Implementing 5S

5S starts you off on the right foot. It’s a perfect tool forbringingateamofcliniciansandstaffmemberstogetherandallowing themto focuson theirownareasfirst. It teachesthem to focus on their own operation and identify thewaste in theirworkwithoutbeingscrutinizedorcriticizedby others. It establishes the trust and skills needed to gothedistancewithLeanhealthcareserviceproduction.Italsoputs theplace inorder, eliminates the “low-hanging fruit”ofprocesswaste,andestablishesthedisciplinerequiredto

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delve deeply into the process analysis needed to shift tokanban.5S is thefirststep increatingavisualworkplace;kanban,mistake-proofing,andcontinuousflowarethelaststeps.If youdon’tdo5Sfirst,youwillhavetocomebacktoitatsomepoint.

Asafocusforakaizenworkshop,5Smakesagreatfirststepbecauseeveryonecanlearnfromitwithoutriskingthetimeandeffortrequiredtochangethemedicalcenterlayoutentirely.(Thoughsomeequipmentmayneedtobemoved,it willprobablybelessdisturbingtohealthcareservicepro-duction than shifting to continuous flow.) As 5S becomesestablished,processbyprocessandareabyarea,everyonewill see the impact of order and visual mechanisms; themedicalcenterwillstarttopercolatewithanticipationaboutthe possibilities of becoming a Lean healthcare facility. 5Sremovessomanybarriersandcreatessuchasolidfounda-tion for the advancedpullmethods that thereneedbenohesitationaboutchoosing5Sas the focus for initialkaizenworkshops.

Use the5S Evaluation Sheet (Figure 5.3) todetermine ifyouneed tostartwith5Sbefore implementingotherLeanhealthcare serviceproductionmethods. If the chosenarea

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Figure 5.3 a sample 5s evaluation sheet.

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hasanaveragescoreoflessthan3.5, itwouldbegoodtostartwith5S.

5.3.2 Implementing Standard Work

With5Sinplace,cliniciansandstaffmemberswillbegintoidentifyinconsistenciesandinterruptionsintheirdailywork.Inconsistencies and interruptions in the work of cliniciansandstaffmembersaremajorsourcesofvariation,errors,anddefects in healthcare and pose significant risks to patientsafety. The cure for this problem is standard work, which defines repeatable task sequences and timings to ensure that every patient receives the appropriate evidence-based care precisely when they need it.

Byresolvingconflictsamong thedifferent standardsandprotocolsfollowedbyvariouscliniciansandstaff,andbyartic-ulatingstandardswhereperhapsnoneexisted—particularlyinhandoffsbetweendoctorsandnursesandbetweendiffer-entdepartmentsandspecialties in thehealthcare system—healthcareoperationsarestabilizedandqualityandpatientsafetyareautomatically improved.Standardworkcreatesacontextfordatagatheringanddeepproblemsolvingandistheessentialcontextofcontinuousimprovement.

5.3.3 Eliminating Bottlenecks or Improving Setup Times

With 5S and standard work in place, clinicians and staffmembers will begin to identify additional opportunities forimprovement that surface during and after the initialwork-shops.Particularlywithrespectto5S,theseopportunitiesmaybecomethefocusofshorterkaizenevents.Meanwhile,theroll-outofstandardworkmayrequireconsecutiveworkshopsor,insomecases,thecreationofamodel line.Eventually,additionalLean toolsare required toeliminateothernon-value-addingwastesandcreateflow.Traininginquicksetupmethodswillhelpcliniciansandstaffmembersthinkabouttheiroperationsinventively,andyouwillseeareasofWIPinventorydisappear

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assetuptimesimprove.Thiswillbetheindicationthatyouarereadytomovetocontinuousflowandkanban.

Be sure not to get discouraged. Wherever you start in your shift toward continuous flow, problems will arise that you didn’t see before.Thisisthepurposeofthesemethods.Leanhealthcareisallaboutfindingwaste.ThemethodsofLeanarebrilliant in theirability todo this.Behappy—itmeansyouaredoingitright—andmovequicklytoremovewhateverrisesuptoblocktheflowofyournewprocess.

5.3.4 Implementing Continuous Flow, Line Balancing, or Kanban

Weeklong kaizen workshops are most often used first tostabilize the production of healthcare services through theimplementation of standard work. Next, kaizen is used totransformhealthcareserviceproductionlinesbyimplement-ingcontinuousflow,supportedbykanban(acardcontaininga sequencemanufacturing specifications and requirements,used to regulate the supply of components) and pull sys-tems.These activities require major changes in medical center layout and complete transformation of the work standards for every process.Agreatdealofplanningandpreparationareneededbeforehandtoensuresuccess;advancecoveragemustbeadequatetoallowthetargetedoperationstocontinuetofunctionduring theworkshop,payingabsoluteattention topatientsafety.Progresscanbemadeworkshopbyworkshopthroughout the medical center, requiring that an organiza-tionwideplanbemadebeforethefirstworkshopsothateacharea can switch to continuous flow logically and with theleastdisturbancetooverallmedicalcentereffectiveness.

Itmakesagreatdealofsensetoimplement5Sandstan-dardworkthroughoutthemedicalcenterandremovemajorbottlenecksdue to slowsetupsbeforeattempting to installcontinuous flow.Manyof theproblemswill be eliminatedbeforerequiringoperationstofunctionaccordingtothenewstandards, andyouwillhaveachance toeliminateopera-tionsthatexistonlybecauseofprocesswaste.Ifyoushifttocontinuousflowbeforeeliminatingunnecessaryandwasteful

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operations,confusionwillbetheresult.Bystartingwith5Sandstandardwork,cliniciansandstaffmemberswillbecomeusedtosolvingproblemsintheirworkarea,manychangesinlayoutwillalreadyhaveoccurred,andmuchwastewillberemoved,clearingthewayforthemoreadvancedtechniquesofcontinuousflowandkanban.

5.4 SELECT AND PREPARE THE TEAM

5.4.1 Select the Team Leader

Afterchoosingtheareaandtheproblemfocusforthework-shop,theworkshopleaderandprocessownermustidentifytheteamleader.Theteamleaderleadstheteamconductingtheworkshop,andworkswiththeworkshopleadertoprovideinputtothesponsorandprocessowneraboutwhoshouldbeontheteam.Heorshealsohelpspreparefortheworkshop,creates schedules, gathers the needed supplies and instru-ments,andfollowsallworkshopactivities,removingobstaclesandhelpingwith documentation and reporting. The leaderkeepstheteamontarget,ensuringthattheymeetthework-shopobjectives.Teamleadersshouldbeselectedfarenoughaheadoftheworkshopsothattheycanrearrangetheirsched-ulestomakeleadingtheworkshoptheirtoppriority.

Leaders must have participated in a kaizen workshopbeforeleadingone,but theydonothavetoknowhowtosolvetheproblemsonwhichtheworkshopisfocused.Theirroleistosupporttheteammembersinfindingsolutions—tofacilitateanopenexchangeofideasandtoaskthequestionsthatspurcreativeproblemsolvingamongtheteammembers.A teamleadermaywork in theareachosenfor thework-shop,but team leadersshouldalsobeencouraged togainexperiencebyleadingteamsinotherareasofthefacility.SeeFigure 5.4forthequalitiesagoodteamleadershouldhave.

5.4.2 Prepare the Team Leader

Team leaders will need to become familiar with the A3Tchartersothattheyunderstandthegoalsandobjectivesofthe


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workshop, the healthcare service production requirements,and the expectations of team members. Information frompastworkshopsshouldbesharedwiththeteamleader,suchaspastproblemsencounteredandgainsachieved.Theteamleader should also be given information aboutwhat to doinanemergency,safetyrulesrelatedtothearea,whattodowhenthingsbogdown,howtohandlepersonalityconflicts,andwhere to access needed data. In addition to selectingthe team members, the leader has a number of responsi-bilitiesandactivitiesbefore,during,andaftertheworkshop.Figure 5.5listssomeoftheworkshopleaderandteamleaderresponsibilities,andhowtheysupportoneanother.

5.4.3 Select the Team Members

The team leader’s first responsibility is to work with theworkshopleaderandprocessownertoselectteammembers.Theteammembersarethepeoplewhoactuallyconductthekaizenworkshop.Allteammembersmustbeabletopartici-pateintheentireworkshop,withnoexceptions.Iftheyare


Qualities of a Good Team Leader

a good team leader should have the following qualities and experience:

1. Previous leadership experience; not necessarily management experience, it can be experience as a scout leader, soldier, mother, etc.

2. experience as a leader or coleader in other kaizen workshops; must have at least participated in a previous workshop

3. an awareness of the methods of Lean healthcare

4. a good leadership style (that is, socratic versus dictatorial or didactic)

5. an understanding of participative management

6. Be able to be firm but fair, aggressive and friendly

7. Be able to take control when necessary

8. Be willing to be out on the floor for the event, not out of reach in the office

Figure 5.4 the qualities of a good team leader.

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Kaizen Workshop Roles and Responsibilities

Workshop Leader (WSL)

◾ Accountable to sponsor

◾ Responsible for workshop flow, target metric achievement, and quality of final product

Planning

◾ attend all planning meetings.

◾ in coordination with team leader (tL), facilitate weekly planning meetings beginning 4 weeks prior to the workshop. (refer to 4-3-2-1 checklist, figure 5.8.)

◾ in coordination with tL, responsible for preworkshop gemba (gemba is a Lean term derived from a Japanese word meaning “the real place”; it refers to the actual place where healthcare processes are performed) observations and data collection.

◾ Work with sponsor to establish workshop target metrics.

During the Workshop

◾ ensure adherence to kaizen week standard work and agenda items and allotted times.

◾ assist tL with setting up the daily agenda.

◾ Work with tL to divide kaizen team into subteams by grouping idea summary sheets (see figure 6.8) into categories/projects.

◾ With tL, report out to process owner (Po) and sponsor on Monday of workshop to review targets, and on tuesday and Wednesday to review progress/summary of the day’s work.

◾ obtain/coordinate support services resources as needed.

◾ take lead in working with any team member exhibiting disruptive or negative behavior, or who is otherwise significantly impacting progress of rest of team; escalate to management or sponsor if needed.

◾ in coordination with tL, create Kaizen action Bulletin (see figure 7.3).

◾ Create final report-out presentation.

◾ Collect all final versions of documents created during the workshop and save to UsB drive for hand off to Po and Kaizen Promotion office (KPo).

Figure 5.5 team leader and workshop leader responsibilities.

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After the Workshop

◾ Huddle with tL, Po, and sponsor to discuss any concerns or issues regarding implementation.

◾ Hand off final documents (UsB drive) to Po and KPo.

Team Leader (TL)

◾ Accountable to workshop leader

◾ Responsible for managing and facilitating the team to deliver the final product

Planning

◾ attend all planning meetings.

◾ in coordination with WsL, facilitate weekly planning meetings beginning 4 weeks prior to the workshop. (refer to 4-3-2-1 checklist, figure 5.8.)

◾ in coordination with WsL, responsible for preworkshop gemba observations and data collection.

During the Workshop

◾ responsible for hands-on facilitation of kaizen workshop.

◾ Work with WsL to divide kaizen team into subteams by grouping idea summary sheets (see figure 6.8) into categories/projects.

◾ Work with WsL to create a daily agenda.

◾ ensure the kaizen team continuously focuses on the Lean process and principles.

◾ demonstrate effective facilitation by not “telling” the team solutions or answers; rather, coach and ask questions to help them get to their own solutions.

◾ support team on gemba.

◾ escalate issues and barriers to WsL, as appropriate.

◾ support WsL in reporting out to sponsor and Po on Monday of workshop to review targets and on tuesday and Wednesday to review progress/summary of the day’s work.

After the Workshop

◾ Huddle with WsL, Po, and sponsor to discuss any concerns or issues regarding implementation.

Figure 5.5 (continued)

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unabletoattendanyportionof theworkshop, theyshouldnotbeontheteam.

Thereshouldbeatleastsixandnomorethantwelvepeo-pleontheteam.Mostshouldbecliniciansandstaffmembersfromtheworkshoparea.Thesepeopleknowtheoperationsandprocessesandcananswerquestionsaboutthearea.Butitiscriticalthatatleastthreemembersbedrawnfromoutsidetheworkshop area. Thesepeoplewill bringnewperspec-tives.Also, try to includeapatienton the team. Itmaybedifficulttoidentifyapatientthatcancommittobeingpresentfortheentirefive-dayworkshop.Trytofindavolunteerorstaffpersoninanotherdepartmentthathasbeenafrequentorrecentpatientinthearea.

Teammembersmustbechosen for their ability toworktogetherandalsobecausetheyunderstandandsupportthepotentialof thekaizenworkshop.Thosewhocomplainorbelittlethepotentialwillslowdownorevenblocksuccess,especiallyforthefirstfewworkshopsyouimplement.Oncesuccessful workshops have been led, these naysayers maybecomeyourstrongestparticipants,butinthebeginningtheyshouldbeleftoffofworkshopteams.Theworkshopleader,thesponsor,andtheprocessownercanhelptheteamleaderidentifythosewhowillmakestrongteammembers.

Improvement methodologies work best when partneredwithpositiveattitudes.SeeFigures 5.6and5.7 forattitudesthatwillgetinthewayofkaizenandLeanhealthcare.These

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TAKE FIVE


1. Would you like to be included in a kaizen workshop team? Why?

2. What qualities do you think make a good team member?

3. Who do you work with that has the qualities of a good team leader?

4. Who actually conducts the kaizen workshop?

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Taboo Phrases

When talking about improvements, never say the following:

1. “do it yourself!”

2. “We can’t get costs any lower.”

3. “this is good enough.”

4. “i’m too busy to do it.”

5. “that’s not part of my job.”

6. “i can’t do it.”

7. “it won’t work in healthcare.”

8. “it’s your responsibility, not mine.”

9. “We’re already doing fine. We don’t need to change.”

Figure 5.6 taboo phrases for kaizen and Lean production.

Ten Arguments That Need to Be Addressed

1. Kaizen won’t do any good!

2. it sounds like a good thing, but we still don’t want to do it!

3. Looks good on paper, but …

4. Costs are already as low as they can possibly get!

5. But we’ve already been doing things that way!

6. We don’t want people looking over our shoulders and telling us what to do!

7. We can’t lower costs any more without lowering quality!

8. everything is going just fine now. Why change it?

9. that’s a lousy idea! We already tried that twenty years ago!

10. Look, we understand this stuff better than anybody (so don’t tell us what to do).

Figure 5.7 ten arguments against kaizen that need to be addressed.

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needtobeaddressedonanorganizationwidescale.Themost

effectiveway is to give teammembers real empowerment

intheseworkshopsandthentocommunicatetheirpositive

resultstothewholemedicalcenter.

5.5 OTHER PREPARATIONS

5.5.1 Prepare the Area

Preparationoftheworkshopareacanmakeorbreakakaizen

workshop.Withoutmeticulouspreparation,therecanbeno

successful kaizen. This is usually the responsibility of the

processowner.Theareachosenfortheworkshopshouldbe

uncluttered;otherwisetheworkshopwillbespentremoving

junkandcleaningupthearea.Iftheareaistoomessy,the

teamleaderandworkshopleadershoulddiscusstheneedfor

startingwith5S,eitherbeforetheworkshoporasthefocus

oftheworkshopitself.

Preparationforakaizenworkshopbeginsweeksinadvance.

The Kaizen Workshop Planning Checklist, or “4-3-2-1” Checklist

(seeFigure 5.8)capturesthemanyactivitiesrequiredtomake

theworkshopasuccess: logistics, teamneeds,communica-

tions,andfinancialandsupportpersonnel.

Remember, it isessential toensure that thesponsorand

processownercommunicateaboutkaizenactivity:

1.Senior leaders should send an announcement (from

thetopoftheorganization).

2.Postthescheduleanddescribewhatwillhappen.

3.Communicatedaily.

4.Involvetheunion.

5.Showbeforeandafterpictures.

6.Thank maintenance and others who support kaizen

activity.

7.Don’tstopcommunicatingaftertheworkshopisdone.

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5.5.2 Prepare Supplies, Equipment, and Support People

If theneededsupplies,equipment,andsupportpeoplearenotinplace,theworkshopwillfail.Makesurethereissuf-ficientlightingandventilationinthearea.Securitymayneedtobenotifiedoftheworkshopsothattheywillbealertedtoanyunusualactivitiesthatwillbeoccurring.

Support departments such as Engineering, EnvironmentalServices,Facilities,andITneedtobeputonalert.Theteammayneedpersonneltorespondquicklytohelpmakeachange,forexampletomoveequipmentorcomputersorinstallshelves.

Teammembersandassignedsupportpersonnelshouldbeeasilyidentifiedduringtheworkshop—givethemteamhats,shirts,vests,orpinstowear,sothateveryoneinthemedicalcenterknowswhotheyareandwhatishappening.

Theteamleaderneedstoprepareasupplykitforthework-shop.ThesesupplykitsaredescribedinChapter6.ASupplies and Equipment ChecklistsuchastheoneinFigure 5.9canhelpkeeptrackofyoursuppliesandequipmentneeds.

5.5.3 Gather Background Information

Considerhowtheworkshopwillaffecttheothershiftsinthatarea.Isitpossibletohavesomeonefromeachshiftrepresentedontheteamsothatchangescanbecommunicatedeasilytoallshiftsaftertheworkshop?Ifhealthcareservicesmustcontinuetobeprovided,understandwhattherequirementswillbeandhow to ensure effective completion of theworkshopwith-outstallingthoserequirements.Alsoconsidertheworkshop’spossibleimpactontheprocessesupstreamanddownstreamof the workshop area. Will the workshop eliminate majorbottlenecksorworkinprocess,orwillitcausethemtoshifttoanotherarea?WillWIPinventorystillbeneededintheareaaftertheworkshop?Ifso,wherewillitbestored?Oristhisoneoftheissuestheteammustsolveduringtheworkshop?

Gathertheinformationyouwillneedtoanswerquestionsthat may arise during the workshop. Time can be wastedsearchingfordatainordertomakedecisionsabouttakttime

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(therateofpatientdemand),processrequirements,andcasemix. Use the Background Information List (Figure 5.10) togathertheinformationyoumayneed.

5.5.4 Schedule the Workshop

A typical kaizenworkshop requires 5½ hours onMonday,8 hoursonTuesday,Wednesday,andThursday,and3–4 hourson thefifthday, Friday.Theworkshop leader andprocessownerneedtodoublecheckwitheveryoneinvolvedinthe

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Figure 5.8 a sample kaizen workshop planning, or 4-3-2-1 checklist.

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workshoptobesurethattheyhaveclearedtheircalendarsforthescheduleddates.Thisisparticularlyimportantinthecaseofbusydoctors,whomay requirenoticeup to ten weekspriortothekaizenworkshop.Remember,100percentpartici-pationisrequiredofallteammemberstheentireweek.It isessential that theyand theirmanagersunderstand this.No

(b)


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Supplies Checklist

Lean Forms:

☐ time observation sheet

☐ standard Work sheet

☐ standard Work Combination sheet

☐ Percent Load Chart

☐ standard Work instruction sheet

☐ standard Work tracking form

☐ standard Work Validation Checklist

☐ red tags

☐ red tag Logs

☐ 5s: 5 Point standardization Checklist

☐ 5s: 5 Point standardization summary

☐ 5s: Job Cycle Chart

☐ 5-minute 5s

Office Supplies:

☐ Pens

☐ Ball Point – black

☐ sharpie – black, red, blue, green

☐ White Board – black, red, blue, green

☐ flip Chart – black, red, blue, green

☐ Highlighter – yellow, pink, orange, green

☐ Pencils

☐ tape

☐ Masking, white

☐ Cellophane

☐ floor Marking

☐ White-out

Figure 5.9 a sample supplies and equipment checklist.

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meetings—noleavingearlyorarrivinglatebecauseofotherworkissues.

Thedatesfortheworkshophaveprobablybeensetfromthebeginningby theworkshop leaderandprocessowner,butnow that theareahasbeenprepared, the team leaderandworkshopleadercanworkoutamoredetailedagenda.Figure 5.11showsatypicalscheduleforaone-weekworkshoptoimplementcontinuousflow.

Tools:

☐ Clipboards

☐ rulers

☐ stopwatches

☐ Calculators

☐ flip Chart

☐ additional flip chart paper

Equipment:

☐ Label Maker

☐ additional cartridges

☐ Laminator

☐ Laminating sheets

☐ PC

☐ Microsoft Word

☐ Microsoft excel

☐ Microsoft PowerPoint

☐ Color Printer

☐ additional ink cartridges

☐ White printer paper

☐ Colored printer paper


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5.6 SUMMARYThefirststepinplanningforakaizenworkshopistochoose

where itwill be conducted.You can choose several areas

where you would like to start and compare the merits of

each. Inorder tohaveabig impact rightaway,choosean

areathatisdelugedwithWIP,thathasactivitiesthatoccurall

overthemedicalcenter,thathasasignificantbottleneckor

othermajorhindrancetohealthcareserviceproductionflow,

orwhereeverythingisamess.Chooseanareawheremost

of the clinicians and staff members are ready and willing

tomakechanges,wherecliniciansandstaffmembershave

alreadybeencross-trainedorhavebeenexposedtokaizen

workshopsbefore, andwithwhichmost of the employees

arefamiliar.

Background Information List

1. Historical or expected patient demand or patient census—by day, week, month

2. Value stream map of the process to be improved

3. Layout map of the area

4. the case mix of different diagnoses and/or acuities in the clinical process to be improved

5. names of clinicians and staff members, their job descriptions, and required levels of licensure

6. Clinic hours of operation and shift change schedules

7. Copies of relevant nursing protocols

8. Copies of relevant organizational policies and procedures

9. CMs or Joint Commission regulations and guidelines

10. articles about any relevant evidence-based practices

11. Par levels or amounts of WiP of supplies needed to allow normal healthcare service production requirements to be met during and after the event

Figure 5.10 Background information list.

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Workshop Schedule

Monday 11:00 a.m. train participants in Lean healthcare concepts and methods.

1:30 p.m. review value stream map, a3t, and targets for the workshop.

2:30 p.m. Go to gemba to observe and document additional process wastes.

4:30 p.m. review progress and scope with workshop sponsor and process owner.

5:00 p.m. first day ends—focal points of improvement activity are well understood.

tuesday 8:00 a.m. Prioritize improvement ideas and form improvement subteams.

9:30 a.m. Go to gemba: observe the process; conduct small tests of change.


5:00 p.m. second day ends—process documentation is complete, more tests of change are planned.

Wednesday 8:00 a.m. return to gemba to continue observations and tests of change.


5:00 p.m. third day ends—most tests of change completed.

thursday 7:00 a.m. Conduct additional tests of change as required.

8:00 a.m. draft new standard work instructions and plan in-service training.

2:30 p.m. Complete new process documentation and final presentation.

3:30 p.m. Practice presentation.

5:00 p.m. fourth day ends—process documentation and presentation are complete.

friday 8:00 a.m. rehearse presentation again and complete workshop evaluations.

9:30 a.m. Make final presentation to the organization.

10:00 a.m. Hand off documents to workshop sponsor, process owner, and KPo.

10:30 a.m. Workshop ends.

Figure 5.11 a typical workshop schedule.

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Oncetheareahasbeenselected,thefocusforthekaizenworkshop must be decided. In selecting a focus for thekaizenworkshop,severalthingsneedtobeconsidered.Has5Sbeenconducted there?Has standardworkbeen imple-mented to stabilize healthcare service production? Shouldthatbe the focusof thefirstworkshop in this areaordoyouwant to implement5Smoregraduallybeforeconduct-ingtheworkshop?Shouldstandardworkbetheinitialfocusofimprovement?Thecomplexityinvolvedandthelengthoftimeneededtoprepareforyourkaizenworkshopdependsontheproblemyouchoosetoimproveortheimplementa-tionyouwishtolead.Thesealsodeterminethelengthoftheworkshopitself.

Thefirstchallengeofkaizenistounderstandhowtoiden-tifywaste.Firstyouexaminewhatis;youpaycloseattentiontowhatyoudothatisvalue-addedandwhatyoudothatisnot. And then you experiment with ways to eliminate thethingsyoudothatarenotvalue-added.Problemsolvingistheheartofkaizen.Itbeginswithoneidea.Anditneverends.

Continuous flow, mistake-proofing, pull systems,andkanban areadvancedLeanmethodsthathavegrownfromthesimplebeginningsof identifyingwaste inorder toeliminateover-production,excessinventory,andunnecessarytransportfromvalue-added operations and processes. Kaizen workshopscanfocusonimplementingtheseadvancedtechniquesandtheyareoftenusedforthispurpose,butitiswisetoimple-mentsimplerapproachestoidentifyingandeliminatingwastefirst.5Sstartsyouoffontherightfoot.It’saperfecttoolforbringingateamofcliniciansandstaffmemberstogetherandallowing them to focus on their own areas first. Standardworkisanexcellentwaytofollow5S.Notonlydoesstandardworkstabilizetheproductionofhealthcareservices,itelimi-natesagreatdealofwasteandsetsthestageforgatheringthedatarequiredtoimplementmoreadvancedLeanhealthcaremethodsincludingcontinuousflowandmistake-proofing.

After choosing the area and the problem focus for theworkshop, the team leader must be identified. The team leader leads the teamconducting theworkshop;heor shehelpschoosetheteammembers,createsthedailyschedules,

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gathers the needed supplies and instruments, and followsallworkshopactivities,removingobstaclesandhelpingwithdocumentationandreporting.

The team members are thepeoplewhoactuallyconductthekaizenworkshop.Theymustbechosenfortheirabilitytoworktogetherandbecausetheyunderstandandsupportthepotentialofthekaizenworkshop.Thereshouldbeatleastsixandnomorethantwelvepeopleontheteam.Mostshouldbecliniciansandstaffmembersfromtheworkshoparea,butoutsiderscanbeusefulmembers,too.

Preparation of the workshop area can make or break akaizen workshop. The area chosen should be uncluttered;otherwise the workshop will be spent removing the junkandcleaningupthearea.Iftheneededsupplies,equipment,andsupportpeoplearenotinplace,theworkshopwillfail.Supportdepartmentswillneedtobenotifiedoftheworkshopsothattheywillbealertedtotheunusualactivitiesthatwillbeoccurringandreadytoprovideassistanceifneeded.

Considerhowtheworkshopwillaffecttheothershiftsinthatarea.Alsoconsider theworkshop’spossible impactonthe upstream and downstream processes of the workshoparea.Gathertheinformationyouwillneedtoanswerques-tionsthatmayariseduringtheworkshop.Timecanbewastedsearchingfordatainordertomakedecisionsabouttakttime,process requirements, and case mix. Use the BackgroundInformation List to gather the information you may need.Thencreatethedetailedschedulefortheworkshop.

5.7 REFLECTIONS





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Chapter 6

Phase TwoRun the Kaizen Workshop

Theareahasbeenselectedandprepared.Keypersonnelareonhandforneededsupport,andsupplieshavebeengatheredforreadyuse.Thefocusforthekaizenwork-shophasbeenselectedandanagendahasbeencare-fullythoughtout.Itisnowtimefortheworkshopitself.

6.1 ORIENTATION

Thekaizenworkshopbeginswithanorientationsessionconductedbytheworkshopleader(seeFigure 6.1).Thesessionshould includeabriefoverviewofLeanmeth-odology,asanintroductionfornewparticipantsandareview for any teammembers that have someexperi-encewithkaizen.

6.1.1 Introduce the Team and Assign Roles

In thebreakout roomyouhavearranged for the teammeetings, have the team leader and team membersintroducethemselvesanddescribetheirjobs,whattheydooutsideofwork,andwhattheyknowaboutkaizenworkshops. Explain the workshop leader and teamleaderroles.

Thendiscusstheteammemberroles.Ifappropriate,assignsomeoneontheteamtoshootvideoand/ortakedigital photos before, during, and after theworkshop.Throughplayback,videodocumentationcanhelpyouanalyze operations and determine opportunities forimprovement.Thesevisualrecordscanalsomakevalu-able additions to your presentation at the end of theworkshop.Photosareespeciallyusefulwhenperforming


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5S improvements.However, ifyouplan to shootvideosortakephotosof areasorprocesses, be sure that you checkyourfacility’spoliciesbeforehand.Introducethemaintenanceorothersupportliaisonandidentifyateammemberwhowillworkwith the support teamasneeded toplanequipmentmovesorotherneedsthatwillariseduringtheworkshop.

6.1.2 Introduce the Workshop Objectives and Procedures

Introducetheobjectivesoftheworkshop.Whatwilltheteambeexpectedtoachieve?Howwilltheworkshopbeconducted?Telltheteamaboutanyadditionaltrainingtheymayreceivebeforetheworkbegins,orbrieflyreviewanytrainingthathasalreadyoccurredandgivetheteamtimetoaskquestions.

Team members will be required to participate without interruption throughout the workshop. Thebreakout roomshouldbequiet,withrefreshmentsandmealsprovidedandrestroomfacilitiesnearby.Nocellphoneorjob-relatedinter-ruptionsshouldbeallowed.Allworkshopkititemsandflipcharts,white boards, andmarkers should be provided in

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Figure 6.1 orienting the team.

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theroomwheretheteamwillgathertoanalyzedata,shareideas, take breaks, and create the presentation.However,themajorityoftheworkshoptimewillbespentinthefocusarea. Infact,all key players should know that their kaizen time will be best spent on the floor—not behind a desk (see Figure 6.2).

6.1.3 Distribute Team Supply Kits and Resources

Theteamreceivesakitofsuppliesforuseduringthework-shop. The team kit should include paper for writing andsketching,pens,pencils,erasers,tape,Post-it®notes,felt-tipmarkers in several colors, stopwatches, andanyother sup-plies theymayneed to illustrate ideas andworkout solu-tions.Eachmemberalsoreceivesanotebookofworkformsneededintheworkshop,anoverviewoftheprocess,andtheworkshopagenda.

After reviewing the teamkitsandnotebooks, the teamleaderdescribesthesharedresources,listedinthefollow-ing text, thathavebeengathered to support the team intheir analysis of the processes in the area and in theirimprovementactivities.

K e y P o i n t

Figure 6.2 Where does kaizen happen?

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Thesharedresourcesincludethefollowingitems:

1.Valuestreammaps,flowcharts,andprocesssheets 2.The A3T or team charter that has sanctioned the

improvementactivity 3.Medicalcenterlayoutsandworkshoparealayouts 4.Photosofthearea 5.Cycle times of current processes (cycle time is the

amountoftimeittakesforaclinicianorstaffmemberto complete anoperationor sequenceof tasks in ahealthcareprocess)

6.Patientdemandrequirementsortakttime 7.Currentstaffandsupportpersonnel 8.Defectandreworkdata 9.Casemix 10.Averagenumbersofsetupsperday 11.Listofcurrentproblems 12.Currentimprovementprojectsbeingconsidered 13.Goalsandobjectives 14.Safetyissuesandrules 15.Healthcareorganizationandunionrules

6.1.4 Conduct Lean Healthcare Training

WhenanorganizationbeginsitsLeanjourney,mostoftheinitialtrainingisfocusedonseniorleadersbeforeimprovementactiv-itybeginsinearnest.PeopleintheorganizationwhoareclosetodailyoperationsoftenknowverylittleaboutLeanhealth-careorkaizen.Therefore,atypicalkaizenworkshopincludesabrieftrainingsessioninbasicLeanconceptsandLeantools.InadditiontotheoverviewofLeanconceptsandmethodolo-gies,theteamwillneedtounderstandanyspecifictoolsandmethodstheywillusetomeettheobjectivesoftheworkshop.Thistrainingwillcontinuethroughthefirstdayasthework-shopproceeds,andnormally includesawaste walk focusedondiscoveringexamplesofthesevenwastes(see Chapter2,Figure 2.1)intheworkareachosenasthefocusoftheweek’simprovementactivity.Additionaltraininginspecifictools,nota-blytherunningtimestudy,isconductedonajust-in-timebasis

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throughout thekaizenweek. If5S is thefocusof thework-shop, then trainingwilloccurat thebeginningofeachdayasyoumovetothenextsegmentofimplementation.Evenifpeoplehavebeenthroughtrainingsessionsinthesemethodspriortotheworkshop,youwillwanttoreviewthetoolsnowsothattheteamhasafreshperspectiveofhowtoproceed.

6.1.5 Set Ground Rules

Astheteambeginsworkingtogether,havethemsetgroundrules about how they will interact during the week. Askthem:“Whatbothersyouinmeetings?”Examplesofgroundrulesinclude:

◾ Nosideconversations◾ Mustraisehandbeforespeaking◾ Putallcellphonesonvibrate

Also,makesureeveryoneunderstandsanyconstraintsthatmay exist related to moving equipment, changing medicalcenterlayout,orspendingmoneytoimplementsolutions.

Goodteamworkbehaviorswillmaketheworkshopmoreenjoyableaswellasproductive.Reviewthetenkaizenwork-shopruleswitheveryone(seeFigure 6.3).Askforcommentsandaskforeveryone’sagreementtotherules.

Reviewtheagendafortheworkshopuntileveryoneisclearaboutwhatwillbeexpected.Itwillbehardworkandevery-onemustunderstandwhattoexpectandthattheymustworktogethertomakeagreatworkshop.

TAKE FIVE


1. What are the three kaizen workshop rules that you like best?

2. What training in Lean healthcare methods have you already had?

3. do you know the cycle time of your own operation?

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6.2 UNDERSTAND THE CURRENT SITUATION IN THE GEMBA

Aftertheorientationandtraining,theteamneedstounder-standthecurrentsituationinthegemba—thatis,intherealplacewherehealthcarehappens,on thefloor, in the focusarea.Itisessentialforallteammemberstophysicallyobservethe processes of healthcare in order to discover the rootcausesofdelaysanddefectsandtounderstandwhattypesofcountermeasuresmayactuallywork.

Dependinguponyourworkshopfocus,youmayormaynot takeallof thestepsanduseallof the toolsdiscussedhere.Thepoint is todowhateveryouhave todo to fullyobserve,record,andunderstandthebaselinesituation.

6.2.1 Observe the Selected Area and Gather Data

Reviewthelayoutand,ifavailable,thebeforephotosoftheworkshop area with the team in the breakout room, andthen take the teamto thearea toobserve itandwalk theprocessflow.


Ten Kaizen Workshop Rules

1. there is no rank among team members—one person, one vote.

2. Keep an open mind to change.

3. Change is good, more change is better.

4. Maintain a positive attitude.

5. don’t blame anyone for anything.

6. respect one another.

7. there is no such thing as a dumb question.

8. Plans are only good if they can be implemented. Plans succeed only if the gains are sustained.

9. there is no substitute for hard work.

10. Just do it!

Figure 6.3 attitudes for success.

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Gatherdatatoperformacasemixanalysis.Grouppatientsbycommonprocessesandoperationsandthenindescend-ingvolumeorder.SelectacaseusingaParetoanalysis,whichwill helpyouchoosean improvement target thatwill giveyouthemostreturnforyourefforts.

Gatherqualitydata,defectrates,andthesourcesofdefects.Walk the route that patients travel andmeasure travel dis-tance. Calculate square feet occupied by the current pro-cess.Investigatesetups—howmanyandhowoften;identifybottlenecks and what causes them. Note current staffing.Determineallsupportpersonsassignedtothearea.Use Time Observation Forms(discussedinSection6.2.3)andStandard Work Sheets (see Figures 6.4aand6.4b) to collect andplotthe data.

Inworkshopsfocusedonimplementing5S,standardwork,quicksetuptimes,orcontinuousflow,baselinedatacollectionwillbedonetoservethoseobjectives.RefertotheotherbooksinthisLeanToolsforHealthcareSeriesfordetailsaboutthemethods,instruments,andmeasuresneededtoimplementthevariousLeanhealthcareimprovementsinakaizenworkshop.

6.2.2 Review the Value Stream Map

Prior to your workshop, you should have created a valuestreammaporperhapsanother typeofprocessmap.Thishelpedyoutoidentifyareasofwastethatmightbeeliminatedthroughkaizenactivity.Typicallyakaizenworkshopwillnotfocusonalloftheoperationsidentifiedintheprocessthatyouhavemapped.Theworkshopwillfocusonasubsetofoperationsorperhapsonasingleoperation(seeFigure 6.5).

Toestablishandmaintaintheproperfocusfortheevent,reviewyourmapbeforeyoubeginthedatacollection,andcompleteaPre-Kaizen Target Sheet(seeFigure 6.6).Herearesometipsforcompletingthetargetsheet:

1.Before the kaizen workshop, enter metrics in theBaseline column.Youwill enter the revisedmetricsondays1through3andattheendoftheworkshopintherespectivecolumns.

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standard work sheet date of observation:area/location:subject obeserved(pt, nurse, etc):

operationsequence:process:

from:to:

start time:observer:

end time:

Room 101 Room 102 Room 103 Room 104 Room 105 Room 106

Storeroom Nurses station kitchen

6 4

6 3 4 3

1

Room 112 Room 111 Room 110 Room 1095 2 5 6

Room 108 Room 107

quality check safety precaution standard WIP # pieces of WIP takt time elapsed time for one observation

(a)

standard work sheet date of observation:area/location:subject obeserved(pt, nurse, etc):

operationsequence:process:

from:to:

start time:observer:

end time:


Storeroom Nurses station kitchen1


quality check safety precaution standard WIP # pieces of WIP takt time elapsed time for one observation

2 3

41

2Technical support

IOW: information on wheelsTelephoneScheduleOrder of rooms visited

RN

(b)

Figure 6.4 standard work sheets for a nursing floor, before and after kaizen.

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2.NeverenterTKorTBM(“tocome”or“tobemeasured”)asametric.Eitherusedatafromsimulationsor,ifthereisnonewdatatoreport,carryforwardthebaselinemetric.

3.Foranymetricsthatwillbetracked,addaspecifictargetmetric(toreplacethepercentage)intheTargetcolumn.

4.Recalculatethepercentchangeateveryremeasurementusingthemostrecentvalue,andlist it inthePercentChangecolumn.Itisalwaysexpressedasapercentagechangefrombaseline[(Baseline−MostRecentValue)/Baseline], not the percentage change from the mostrecentmeasurement.Apositivevalueindicatessuccess.

5.Herearerecommendationsonhowtocalculateeachmeasure:

◾ Space:squarefootageoffloorspaceused.◾ Inventory:monetaryvalueofsupplieskeptinthearea, regardlessofwhether theycanbe returnedforcredit.

◾ Walkingdistance:numberoflinearfeetwalkedbycliniciansandstaffmembersintheprocess.(Note,thisalsorepresentstimespent!)

◾ Partstraveldistance:numberoflinearfeettraveledbyapatientorapartduringtheprocess.

◾ Leadtime:totalnumberofminuteselapsedintheprocess,frombeginningtoend.

◾ Quality (% defects): percentage of defects in theprocess.

pee test diagnosewait wait wait

CT = 10

VA = 5

CT = 10

VA = 5

CT = 75

VA = 50

WITHIN SCOPE

Figure 6.5 a targeted subset of operations—not the whole value stream—is chosen as the focus area.

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◾ Productivitygain:differencebetweentheannual-ized labor required tocompleteaprocessbeforekaizenandthelaborrequiredafterkaizen.

◾ Environmentalhealthandsafety(5S):levels1to5,asassessedwithstandard5Saudittools.(ThefinalscoreisthelowestofthescoresassignedtoSort,Setinorder,andShine.)

◾ Setup: total number ofminutes elapsed betweentheendofthelastgoodprocedureandthebegin-ningofthenext.

◾ Other: used to capture gains (usually financialgains)thatdon’tfitintotheothermetrics.

6.2.3 Do Time Studies of All Operations

If theworkshop focus is 5S, set up red tag areas and fol-low the steps of the 5S process. Otherwise, the next stepistodotimestudiesoftherelevantoperations.Talktothecliniciansandstaffmembersbeforeyoudothisanddiscussthe reasons you are observing them. Fill in your calcula-tionson theTime Observation Form (Figure 6.7).Compareorcalculatetakttimeandcalculateleadtime.Documentanyuniqueprocessorhandlingrequired.Notesetupfrequenciesandtimes.CreateaStandardWorkSheetoftheflowsinthearea.TheStandardWorkSheetisalsocalledaspaghetti dia-grambecausewhenyouaccuratelydepictallthemovementthattypicallyoccurs,themassoflinesresemblesspaghetti.(You can refer to the Standard Work for Healthcare bookin this series for information about how to use the toolsmentionedthroughoutSection6.2.)

N e w T o o l

TAKE FIVE


1. What would a spaghetti diagram of the area you work in now look like? draw one.

2. How would you do a time study of your area?

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6.3 DEVELOP IMPROVEMENTS

Nowthattheteamhasthoroughlyobservedthecurrentsitu-ationandhasaclearerunderstandingoftheactualsituation,theycanbegintoidentifyimprovementprioritiesandactu-allydevelopandtestimprovements.

6.3.1 Generate and Capture Improvement Ideas

Whentheteamreturnsfromgemba,teammemberswilluseIdea Summary Sheets to draw a picture of their personal


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Figure 6.7 a sample time observation form.

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visionsforimprovement(seeFigure 6.8).Askeachteammem-bertodrawatleastthreeideas.Everyoneneedstodraw,notjustwrite,theirideas.Byrequiringpeopletobothwriteanddrawtheirideas,ideasummarysheetshelppeoplearticulateandcommunicatecomplexideasquicklyandeffectively.Theteammustdoideagenerationsilently—nodiscussion.

6.4 FACILITATE TEAMWORK

Keep in mind that, as teams implement ideas or run intoproblems,theworkshopleadermayneedtoreprioritizesev-eraltimesduringtheweek.Teamsthataretoolargewillnot

TAKE FIVE


1. What are the seven types of waste? Can you identify any of these in your own work area? What causes this waste?

2. What could you do to eliminate them?

Figure 6.8 a sample idea summary sheet.

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functionwell.Inparticular,itwillbedifficultforeveryoneonalargeteamtoparticipateeffectively.Duringthecourseofafive-dayworkshop,thiscangiverisetosignificantfrustration,especiallyamongdoctorsandexecutives.

Toensurehighparticipationlevels,breaklargeteamsintosmallgroupsorsubteams.Makesurethateachsubteamhasitsownappropriate leader.Right-sizeteamsthroughout theweektoensurethatsmallgroupinteractionisalwayslively.

Theworkshopleadershouldroundonallsubteamsatleasttwice a day tomake sure that subteam leaders keep theirteamsfocusedandthatteamshavetheresourcestheyneed.Team leaders should stay in gemba with their subteams.Subteamsmustallconvene toreport toeachotherbothatmiddayandat theendofeachday.There isoftenoverlapamongtheiractivitiessotheymuststayupdatedonwhattheotherteamsareworkingon.

Theroleoftheworkshopleaderistocoach,nottosolveproblems.Don’tgiveintothetemptationtobeastarplayer.UseopenquestionstoprovokeLeanthinking!Note:Ifsub-teamsneedsupportdepartmentscalledin,theymustmakethoserequeststhroughtheworkshopleader.Allsuchrequestsmustbecoordinatedtoavoidduplicateand/orinappropriateorunnecessaryrequestsfrommultipleteammembers.

Keeptheenergylevelhigh.Listencarefullytothetoneofteamandsubteaminteractions.Isitharmonious?Discordant?Is everyone involved?Youcaneasily tellwhenpeopleareengagedordisengaged.Beproactive.Respondappropriatelywithhelpfulquestions todiscover thecausesofprolongeddiscordorsilences.Remind teammembersof theexpecta-tionsyousetonMonday.

6.5 TEST IDEAS AND IMPLEMENT THE NEW PLAN

During thekaizenweek, subteamswill test their improve-mentideasingemba.ThetestingofideasshouldbeginnolaterthanWednesdaymorning.AlltestsshouldbecompletedbyWednesdayevening,althoughsubteamsmaycomeearly

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totheworkshoponThursdaymorningifthereareadditionalteststorun.

Ifappropriateandconsistentwithyourfacility’spolicy,trytodocumenttheareausingcameraand/orvideobeforeyouchange it. A picture says a thousandwords. Especially for5Sactivities,apairofbeforeandafterpictures,takenfromexactlythesamespotandatthesameangle,saysvolumes.Beforeandafterpicturesofimprovedprocessesaretheverybestformsofevidence.

The workshop leader should notify the maintenance orothersupportstaffwhenyouarereadytochangethefloorormakeotherchangesthatrequiresupport.Cleanouttheareaoffocus,leavingonlywhatisrequiredforthenewprocess.Markthefloorasneeded.Ifequipmentneedstobemoved,makeadetailedlayoutwithinstructionsformaintenancesothattheycanmakethemovesduringthenightifnecessary.Note any areas needed for WIP, setups, instruments, andothersupportfunctionsintheprocess.

Figure 6.9showsanexamplefromanORkaizenworkshopintheAmbulatoryCareUnit(ACU)beforeandafter5S.

Figure 6.9 a storage area, before and after kaizen.

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After implementing their improvement ideas, subteamsobservetheworkbeingperformedinthenewway.

1.UsetheTimeObservationFormtorecordnewcycletimes.

2.DocumentthenewstandardusingtheStandardWorkInstructiontemplate.

3.Communicate,communicate,communicate.

Then, encourage the team to find more ways to maketheworksafer,easier,quicker,andmoreconsistent.Dothis

Figure 6.10 a sample standard work instruction sheet.

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againandagain.Kaizenisneverfinished;youjustrunoutoftime.

Trainthecliniciansandstaffmembersinthenewprocessandtestituntilitisrunningsmoothly,attheimprovedlevel.Observeandrecordnewcycletimes.Noteanyproblemsandcheckforsafetyissues.IsthereenoughWIPattheneededlocations?Calculateallsavingsfromtheeliminatedwaste:cli-nicianorstaffmembermotion,partconveyance,squarefoot-agetakenupbythenewprocess,throughputtime,andsoon.Completeallprocessanalysissheetsforthenewprocess,includingtheStandard Work Instruction Sheet(Figure 6.10),sothatyoucancompareittotheoldprocessinyourreport.

6.6 DEVELOP NEW STANDARDS

Setnewtargetsanddefinethemeasuresforthenewprocess.Makeyourtargetsasconcreteand/orasquantifiableaspos-sible.Recordallnewdata.Completeasmuchoftheimple-mentation as you possibly can within the workshop timeframe.Whatcannotbeimplementedshouldberecordedona follow-up sheet for completion after the workshop. Theworkshopleaderwillberesponsibleforassigningandseeingthattheseitemsarecompletedinatimelyfashion.

6.7 SUMMARY

The kaizen workshop begins with an orientation meeting.Introducetheteam,assignroles,andintroducetheworkshopobjectivesandprocedures.Teammemberswillberequired

N e w T o o l

TAKE FIVE


1. With all you have learned, do you think you would like to participate in a kaizen workshop?

2. What areas in your medical center do you think should be the focus of kaizen workshops first?

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toparticipatewithoutinterruptionthroughouttheworkshopandthemajorityoftheworkshoptimewillbespentinthefocus area. All key players should know that their kaizentime will be best spent on the floor—not behind a desk.Distributesuppliesandresources.Makesureeveryoneunder-standsanyconstraintsthatmayexistrelatedtomovingequip-ment,changingmedicalcenterlayout,orspendingmoneytoimplementsolutions.Reviewthetenkaizenworkshopruleswitheveryone.Review theagendas for theworkshopuntileveryoneisclearaboutwhatwillbeexpected.Thoughsometrainingmayhavebeenconductedbefore theworkshop,abriefintroductionorreviewwillbeneedednowfortheteamtounderstandtheinstrumentsandmethodstheywillusetomeettheobjectivesoftheworkshop.

After the orientation and training, the team needs tounderstandthecurrentsituationinthefocusarea.Takethestepsnecessarytofullyobserve,record,andunderstandthebaselinesituation.Reviewthelayoutandthebeforephotos(if available)oftheworkshopareawiththeteaminthebreak-outroom,andthentaketheteamtotheareatoobserveitandwalktheflow.Observethearea,gatherdata,completethePre-KaizenTargetSheet,andreviewthevaluestreammapoftheareasothatyoucananalyzetheprocess.Thiswillpre-pareyoutoidentifyareasofwastethatmightbeeliminated.Dotimestudiesofalloperations.Talktothecliniciansandstaffmembers before you do this and discuss the reasonsyouareobservingthem.Identifyandrecordthewastesyoufind in the area. Record themagnitudeofwaste youfind.Search for therootcausesof theproblemandask thefivewhys. Work with the clinicians and staff members to findsolutions.Ask,“Whatwouldthisprocesslooklikeifitwerefreeof waste?”

Withcurrentimprovementtargetsinmind,brainstormtocreatenewideas,usingtheIdea Summary Sheets.Thinkoutofthebox!Meetwithcliniciansandstaffmemberstocollabo-rateonthenewideas.Testtheimprovementideasasmuchaspossiblebeforechangingthelayout.Thenimplementthenewplan.Trainthecliniciansandstaffmembersandtestthenewprocess.Observeandrecorddataforthenewprocess

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andcompareittotheoldprocess.Setnewtargetsanddefinethemeasuresforthenewprocess.

6.8 REFLECTIONS





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Chapter 7

Phase ThreeReport and Follow-Up

Atkeypointsduringtheworkshop(normallyonTuesdayandWednesdayafternoons,aftertheteamisdismissed),theworkshopleaderandteamleadersreportcurrentdailyprogress toworkshop sponsors,whoprovide feedbackandguidancetotheteam.Theworkshopleadermakessurethatthesereportmeetingsstartandstopontime.

Onceimplementationiscompleteandalldataforthenewprocesshasbeenrecorded,itistimetopreparethepresentationofresultsandtocelebrate.

7.1 PRESENTATION

7.1.1 Prepare a Presentation of All Data and Workshop Results

Onthelastdayoftheworkshop,allteammemberspar-ticipateinpresentingtheresultsoftheirkaizenactivityto senior management. Typically the workshop leaderwillcoordinatethepreparationofthepresentationandchoosetheinformationandmaterialstobeincluded.

Thepresentationincludesactualdocumentation,includ-ing standard work sheets, time observation forms, ideasummarysheets,thenewfloorlayoutandspaghettidia-gram,standardworkinstructionsheetsforeachclinicianorstaffmemberand/orstation,illustrationsthatexplaintheimprovements,andbeforeandaftervideosordigitalphotos,ifavailable.Theteamshouldbegincreatingthisdocumentationearlyintheweek.Quantifyyoursuccessintermsthatareimportanttoyourbusiness,suchascostsavoidedorreducedleadtimes.Didyoumeetorexceedyourgoal?Ifyoucameclose,whatelseneedstohappen


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tomeetthegoal?TheworkshopleadercanusethechecklistinFigure 7.1togetreadyforthepresentation.

Onthemorningofthelastworkshopdaybeforethefinalreport,theworkshopleadershouldaskeachteammemberforabriefdescriptionofwhattheylearnedfromtheworkshopper-sonally.CompletetheWorkshop Evaluation Form(Figure 7.2).

7.1.2 Present the Results

On the afternoonof thenext to last day (usually Thursdayafternoon)andagainonthemorningofthefinalday,theteam

N e w T o o l

K e y P o i n t

Workshop Leader Checklist for Report Out

☐ Process is serving patients at takt time with zero defects.

☐ takt time calculations are correct.

☐ Cost–benefit analysis meets finance department standards.

☐ idea summary sheets are compiled.

☐ time observation forms and Percent Load Charts are compiled.

☐ new layouts are documented on standard Work sheets.

☐ new standard Work instructions are completed.

☐ in-service training for clinicians and staff is scheduled.

☐ 30-day Kaizen action Bulletin is complete.

☐ slide presentation completed, including team photo and thanks to all involved.

☐ List made of recommended future improvements.

☐ final reflection on the week’s activities with the team completed.

☐ Workshop evaluations are completed.

☐ final run-through of presentation is complete.

☐ all necessary documentation is complete and transferred to UsB drive.

Figure 7.1 a sample workshop leader checklist for report out.

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Workshop Evaluation Form

date: organization: Workshop Leader:

name: Location: team Leader:

Phone: service Line: sponsor:

e-mail: team name: Process owner:

1. What was your overall impression of the workshop?

2. What would you change about the workshop to make it more useful?

3. Would you like to participate in another workshop, yes or no, and tell why?

4. did the workshop accomplish all that it could, or was there more that could have been done?

5. How were you treated? Could you give your opinions freely?

Poor Great

6. Please rate the Workshop Leader 1 2 3 4 5 6 7 8 9 10

7. Please rate the team Leader 1 2 3 4 5 6 7 8 9 10

8. Quality of training material 1 2 3 4 5 6 7 8 9 10

9. Usefulness to the organization 1 2 3 4 5 6 7 8 9 10

10. Usefulness in your current work 1 2 3 4 5 6 7 8 9 10

additional comments please:

Figure 7.2 a sample workshop evaluation form.

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shouldgather to rehearse thepresentation.The team leadershouldalwaysstartthepresentation.Theworkshopleaderisresponsibleforadvancingtheslidesastheteammembersspeaksequentiallyabouttheirselectedsetofslides.Timeeveryone’spartandassesswhoisgoingontoolong.Helpteammembersrefine or enhance their comments to effectively convey thestoryoftheweek.Thepresentationshouldnotrunmorethantwentyminutes.Eachteammemberparticipatesinsomeway;eventhepresentationsshouldbeateameffort.

7.1.3 Cover Ideas That Have Not Been Fully Implemented

Improvementideasthatyourteamwasnotabletocompleteduring the week are recorded on a kaizen action bulletin(see Figure 7.3).Responsibilityandaduedateareassignedfor each unfinished item. Completion is expected withinthirtydays.OnlyonenamemayappearintheResponsibilitycolumnforanysingleitem.

Althoughmanymayhelp,ultimateresponsibilityforcom-pletion of the bulletin lies with the process owner (whosenameappearsatthetoprightofform).Kaizenactionbulletinsshouldbecompletedbyall subteamleadersandshouldbeincludedaspartoftheirreportonFriday.

7.1.4 Build the Book of Knowledge

Before the workshop concludes, the workshop leader col-lectsalldocumentscreatedduringtheworkshop.Thesemayincludestandardworksheets, timeobservation forms,per-centloadcharts,standardworkinstructions, ideasummarysheets,A3Ts,andbeforeandafterphotos.Thesedocumentsform the coreof your “bookof knowledge” and track theevolutionofyourstandardwork.Theyarethevitalrecordofyourorganizationallearning.Thebookofknowledgeshouldalso include the workshop leader’s final report, a simplereportthatoutlineskeychangesinbullet-pointformat.Thedocuments should be handed to the representatives fromyourKPO(KaizenPromotionOffice).

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7.1.5 Circulate and Display Results

Circulate results to topmanagement and anyone elsewhoshouldhavethem.Displayresultsinacentralareaforpeopleto readat their leisure.Theworkshop leader shouldmakehardcopiesoftheteampresentations,andpublicizethegoodresultstothehealthcareorganization.Theworkshopleaderwillhaveinvitedtheappropriatepeopletothepresentation.Thelogisticsofthepresentationandanycelebrationplannedaretheworkshopleader’sresponsibilityalso.

7.2 FOLLOW-UP

Follow-upisnecessarytoreapthefullbenefitofkaizen.The workshop is, in some ways, never over. Results must be monitored and improvements continually made. Therearealwaysmanythings left to complete. The real success of the workshopwillbemeasuredonlyafterall the recommendationshavebeen implemented.

Thesponsorandprocessownershouldmeetatleastonceaweekforfourweeksfollowingtheworkshopandreviewthestatusofeachkaizenactionbulletinitem.Thisistoensurethatitemsarecompletedwithinthirtydays,thatchangesarebeingsustained,andthattheproposedcountermeasuresarehavingthedesiredimpact.

Theworkshopleaderwillreviewtheresultswiththeexecu-tiveteamandplanthenextsteps,includingsubsequentwork-shopstobeheld.Werethereanysurprisesorfailures?Weretheobjectivesmet?Howcanfutureworkshopsbeimproved?

Evaluation forms should be reviewed by managementand used to inform plans for future workshops. The nextworkshopleadershouldchecktheresultsofthisworkshoptomakesureallthefollow-upitemswerecompleted.Donotstartthenextworkshopuntilthelastonehasbeenfinished.

Cliniciansandstaffmembersonthelinesimpactedbytheworkshopshouldbecontactednomorethanaweekaftertheworkshopforfeedbackonthechangesthathavebeenmade.Makealistof theirsuggestionsorcomplaintsandgivefeed-backtotheprocessowner.Cliniciansandstaffmembersshould

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participateinweeklymeetingstomeasurethenewsystemandconsidertheirideasforcorrectingflawsintheoriginal design.

Resultsofthenewprocessshouldbetrackedandposteddailyonruncharts(simplechartsthatplotaprocessvalueovertime).Afterthirtydays,publishtheresultsandcomparethemtotheoldstandardstoshowtheaccumulatedsavingstodate.UsethePost-Kaizen Target Sheet(seeFigure 7.4)totracknumericprogressof certainmetrics related tokaizenimprovements.Onthissheet,you’llrecordthe30-,60-,and90-dayresultsofthemetricsyoutrackedduringthekaizenworkshop(seeChapter6,Figure 6.6).

Trackthesavingsweeklyforayear.Remember,whateveryoutrackwillimprove.Ifcliniciansandstaffmembersweremovedtootherareasbecauseof theworkshop,makesurethateveryoneknowswhattheyaredoingandthatnonewerereleasedorlaidoff.Thankstothekaizentraining,allclini-ciansandstaffmembersinvolvedshouldbevaluableplayersanywheretheyareplaced.

Remindeveryonethatkaizenismorethanaworkshop—itneverends.Kaizenisnowthewayyoudoyourwork.

7.3 SUMMARY

Onthelastdayofmakingimprovements,teammembersmustrehearse thepresentationbefore they can adjourn.On themorningofthefinalday,theteamshouldgathertorehearsethe presentation. Each team member participates in someway;eventhepresentationsshouldbeateameffort.CompletetheWorkshop Evaluation Formbeforethecelebrationbegins.Circulateresultstotopmanagementandtoanyoneelsewhoshouldhavethem.Displayresultsinacentralareaforpeopletoreadattheirleisure.

The workshop is, in some ways, never over. Results must be monitored and improvements continually made. There arealwaysmanythingslefttocomplete.UsetheKaizen Action Bulletintorecordandtrackto-doitems.Therealsuccessoftheworkshopwillbemeasuredonlyafteralltherecommen-dationshavebeenimplemented.

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Clinicians and staff members on the lines impacted by the workshop should be contacted no more than a week after the workshop for feedback on the changes that have been made.Results of the newprocessmust be posted daily. Use thePost-Kaizen Target Sheettopublishresults,comparethemtotheoldstandards,andshowtheaccumulatedsavingstodateat30,60,and90daysaftertheworkshop.Continuetotrackthesavingsweeklyforayear.Remember,whateveryoutrackwillimprove.

Remindeveryonethatkaizenismorethanaworkshop—itneverends.Kaizenisnowthewayyoudoyourwork.

7.4 REFLECTIONS





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Chapter 8

Reflections and Conclusions

8.1 SUMMARY OF STEPS FOR CONDUCTING A KAIZEN WORKSHOP

Thefollowingsectionsbrieflysummarizethekeystepsforconductingakaizenworkshop.

8.1.1 Phase One: Plan and Prepare

Select aworkshop leader—will you use an out-sideconsultant?

Communicatetotheentirehealthcareorganizationtheplansforakaizenworkshop.

Selectanarea:◾ UsetheKaizenWorkshopAreaSelectionMatrixtodetermineprioritiesforareastobeselected.

◾ Createorreviewexistingvaluestreammaps.Selectaproblemforimprovement.Selecttheteamleaderorcoleadersandpreparethem.Selecttheteammembers.Preparethearea.

◾ Gatherneededsuppliesandequipment.◾ Notify necessary support departments andpeople.

◾ Getneededbackgroundinformation.Scheduletheworkshop.

8.1.2 Phase Two: Run the Kaizen Workshop

Orientation:◾ Introducetheteamandassignroles.

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◾ Introducetheworkshopobjectivesandprocedures.◾ Distributeteamsupplykitsandresources.◾ Conductneededtrainingandsetgroundrules.

Understandthecurrentsituationinthegemba:◾ Observetheselectedareaandgatherdata.◾ Reviewthevaluestreammap.◾ Dotimestudiesofalloperations(orsetupareasfor5Simplementation).

Maketheimprovements:◾ Developimprovementideas.◾ Testideasandimplementthenewplan.◾ Developnewstandards.

8.1.3 Phase Three: Report and Follow-Up

Presenttheresultsofthekaizenworkshoptothehealth-careorganization:

◾ Prepareapresentationofalldataandworkshopresults.◾ CompletetheWorkshopEvaluationForm.◾ Presenttheresultsandcirculatethemtotopmanage-mentandanyoneelsewhoshouldhavethem.

◾ Buildthebookofknowledgebysubmittingalldocu-mentsand thefinal report to theKaizenPromotionOffice.

◾ Displayresultsinacentralareaforpeopletoreadattheirleisure.

Celebratethecompletionoftheworkshop.Follow-up:◾ Use the Kaizen Action Bulletin to assign follow-uptasksandmakesuretheyarecompleted.

◾ Getfeedbackfromthecliniciansandstaffmembersintheworkshoparea.

◾ Document and continue to track results using thePost-KaizenTargetSheet.

◾ Considernextsteps,nextkaizenworkshops,andthenextLeantrainingthatisneeded.

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8.2 REFLECTING ON WHAT YOU HAVE LEARNED

An important part of learning is reflecting on what you’ve learned. Without this step, learning can’t take place effec-tively.That’swhywe’veaskedyou to reflect at theendofeachchapter.Andnowthatyou’vereached theendof thebook,we’dliketoaskyoutoreflectonwhatyou’velearnedfromthebookasawhole.

Take tenminutes to thinkabout the followingquestionsandtowritedownyouranswers.

◾ Whatdidyoulearnfromreadingthisbookthatstandsoutasparticularlyusefulorinteresting?

◾ What ideas, concepts, and techniques have youlearnedthatwillbemostusefultoyouduringkaizenworkshops?Howwilltheybeuseful?

◾ What ideas, concepts, and techniques have youlearnedthatwillbeleastusefulduringkaizenwork-shops?Whywon’ttheybeuseful?

◾ Doyouhaveanyquestionsaboutkaizen?Ifso,whatarethey?

8.3 OPPORTUNITIES FOR FURTHER LEARNING

Herearesomewaystolearnmoreaboutkaizen:

◾ Findotherbooks,videos,ortrainingmaterialsonthissubject.SeveralarelistedintheAppendix.

◾ Ifyourhealthcareorganizationisalreadyconductingkaizenworkshops,visitotherdepartmentsorareastoseehowtheyareapplyingtheideasandapproachesyouhavelearnedabouthere.

◾ Findouthowothercompanieshaveconductedkaizenworkshops.Youcandothisbyreadingmagazinesandbooks about Leanhealthcare implementation, andbyattendingconferencesandseminarspresentedby others.

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8.4 SUMMARY

Kaizenismorethanaseriesoftechniques.Itisafundamentalapproachtoimprovingthehealthcareprocess.Wehopethisbookhasgivenyouatasteofhowandwhythisapproachcanbehelpfulandeffectiveforyouinyourwork.

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Appendix

FURTHER READING

RonaConsultingGroup&ProductivityPress,5S for Healthcare(NewYork:ProductivityPress,2009).Restatestheuniversalconceptandpracticesof5S—creatingaclutter-freeandorga-

nizedworkplace—inalanguagethatspeakstohealthcareprovidersandstaff.RonaConsultingGroup&ProductivityPress,Standard Work for Lean Healthcare

(NewYork:ProductivityPress,2012).Explainshowtoapply thepowerfulLean toolof standard work to increase

patientsafetyandreducethecostofprovidinghealthcareservices.MarkGraban,Lean Hospitals: Improving Quality, Patient Safety, and Employee Satis-

faction, 2nd edition(NewYork:ProductivityPress,2012).Lean HospitalsexplainswhyandhowLeancanbeused to improvequality,

safety,andmoraleinahealthcaresetting.GrabanhighlightsthebenefitsofLeanmethodsandexplainshowLeanmanufacturingstaplessuchasValueStreamMappingcanhelphospitalpersonnel identifyandeliminatewaste,effectivelypreventingdelaysforpatients,reducingwastedmotionforcare-givers,andimprovingqualityofcare.

NaidaGrunden, The Pittsburgh Way: Improving Patient Care Using Toyota Based Methods(NewYork:ProductivityPress,2008).AuthorNaidaGrundenprovides ahopeful lookathowprinciplesborrowed

fromindustrycanbeappliedtomakehealthcaresafer,andindoingso,makeitmoreefficientandlesscostly.ThebookisacompilationofcasestudiesfromunitsindifferenthospitalsaroundthePittsburghregionthatappliedindustrialprinciplessuccessfully,makingpatientssaferandemployeesmore satisfied.

USEFUL WEBSITES

LeanBlog,http://www.leanblog.org/.AblogfoundedbyauthorMarkGrabanaboutLeaninfactories,hospitals,and

theworldaroundus.JohnGrout’sMistakeProofingCenter,http://www.mistakeproofing.com.

104 ◾ aPPendix

Shingo Prize-winner John Grout’s collection of three websites devoted topoka-yoke(mistakeproofing),akeytechniqueforkaizenandLeanoperationsgenerally.Anentirewebsitewithinthecenterisdevotedtomistake-proofingapplicationsinhealthcare.

RonaConsultingGroup,http://www.ronaconsulting.com.TheofficialwebsiteofSeriesEditorThomasL.Jacksonandhispartnersatthe

RonaConsultingGroup.ProductivityPress,http://www.ProductivityPress.com.

ThewebsiteofProductivityPress,whereyoucanorderthebookslistedintheFurtherReadingsectionofthisAppendix,amongmanyotherworksaboutLeanhealthcare,Leanmanufacturing,totalqualitymanagement(TQM),andtotalproductivemaintenance(TPM).

Part of the Lean Tools for Healthcare series, this user-friendly book will help to improve your understanding of kaizen. It describes exactly what a kaizen event is and details all the phases necessary for implementing continuous improvement practices in your healthcare organization.

Kaizen Workshops for Lean Healthcare walks you through the steps of conducting an effective kaizen workshop—one that is well planned, well implemented, and well monitored. The information is presented in an easy-to-assimilate format. Numerous illustrations reinforce the text, and margin assists call your attention to key terms, healthcare examples, and how-to steps.

Throughout the book, you will be asked to reflect on questions that will help you apply the concepts and techniques in your own workplace. Defining the key concepts and elements of the “production” of healthcare services, the text delineates the differences between healthcare processes and the individual cycles of work that those processes link together. It also:

• Provides foundational information on kaizen and kaizen workshops—defining the key roles for success

• Explains exactly how to plan and prepare

• Presents examples of how to present workshop results and how to follow up

• Includes a concise summary of kaizen workshop steps

• Supplies a list of additional resources for learning more about the different kinds of improvement methodologies you might want to implement in your kaizen workshops

If your healthcare organization fully applies the steps detailed in this book, it will gain much more than the knowledge of how to conduct a workshop. Through kaizen, you will empower your employees to make positive change a reality. And incrementally, kaizen workshops will become more than isolated events—they will become the way all work is done in your organization.

Kaizen Workshopsfor Lean HealthcareRona Consulting Group & Productivity PressThomas L. Jackson, Editor

KA

IZEN W

ORK

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EALTH

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Kaizen Workshops for Lean HealthcareRona Consulting Group & Productivity Press


www.product iv i t ypress .com

www.crcpress.com

ISBN: 978-1-4398-4152-5

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