Kaizen

Kaizen Events:
Achieving Rapid Improvement in

Healthcare Settings
Society for Health Systems
Orlando, FL
February 21, 2008
Company
LOGO
Building a Lean Enterprise
KAIZEN
Kai Zen
Break apart Study
To change Make better
EVENT
Rapid Improvement
© 2008 Karen Martin & Associates 3
Improvement Roles
Who? Accountability Tool

Strategic
Leadership “What has to happen” Value Stream

Mapping / A3
Middle
Management
Tactical
Workforce “How it will happen” Kaizen Events

Value Stream Defined
Value Stream: All of the activities, required to

satisfy a customer need from request to receipt.
Value Stream
Process Process Process
Custom er
Customer Customer
Request Receipt
“Order” “Delivery”

Typical Healthcare Value Stream
“Pre-Production”
Appointment
or Need
Admission Determined
Scheduled Start
Patient Evaluation Diagnosis

Patient Patient
Arrival / & &
Discharged Follow-up
Admission Testing Treatment
“Production”
Payment Claim
Received Submitted
End
“Post-Production”
Individual vs. System Performance
Systems focus =
0ptimal value stream
performance
Isolated pockets of excellence =

sub-optimization risk

Customer Demand:
CT=Cycle Time
Current State Value Stream Map 15 patients per Day
(Takt Time = 32 minutes)
LT=Lead Time
%C&A=% Complete & Accurate
Outpatient Imaging Services 8 hours per day
Pre-register Schedule
Patient Appointment
Refer Patient Patient
(Physician) 2
5 4 Lead T ime = 990 mins. 6 3 Lead Time = 12 mins. 2 1
Cycle T ime = 30 mins. Cycle T ime = 11 mins. % C&A = 65 %
Lead Time = 990 mins. Lead Time = 12 mins.
% C&A = 100 % % C&A = 98 %
Auto Fax 50%

Us Mail 25%
MD Mailbox 25%
Rework Loop
Symposium E Pay Excel ADS Meditech Internet Fax Order PACS via Fax 25% of
Waiting Room
Solutions
Management the time
System
Lead Time = 10 days
Read/Dictate Review / Sign Print Send

Check-in Check-in Prep Patient, Conduct Exam Report Reports Reports
Patient Patient Exam, Transmit (Radiologist) (Radiologist) (Imaging) (Imaging)
(Admitting) (Imaging) Images (T ech) T ranscribe Report
(MDI)
5 mins.
5 mins. 80 mins. 248 mins. 8 365 mins. 9 960 mins. 110 mins. 11 120 mins. 12
5 5 3 6 2 7 2 10 2 6
2
Cycle Time = 2 mins. Cycle T ime = 1 mins. Cycle T ime = 28 mins. Cycle Time = 15 mins. Lead Time = 5 mins. Cycle Time = 1 mins. Cycle T ime = 3 mins.
% C&A = 95 % % C&A = 75 % Cycle Time = 1 mins. % C&A = 99 % % C&A = 90 %
% C&A = 90 % % C&A = 98 % % C&A = 90 %
% C&A = 95 %
0.0833 hrs. 0.0833 hrs. 1.33 hrs. 4.13 hrs. 6.08 hrs. 16 hrs. 1.83 hrs. 2 hrs. LT = 32.5 hrs.
2 mins. 1 mins. 28 mins. 15 mins. 5 mins. 1 mins. 1 mins. 3 mins. CT = 56 mins.
CT/LT Ratio = 2.87%
Rolled First Pass

Value Stream Champion: Paul Scanner yield = 30%
Created July 19, 2005

Key Metrics: Time
Process time (PT)

The time it takes to actually perform the work, if one is
able to work on it uninterrupted
Includes “think” time if process is analytical in nature
aka “touch time,” work time, cycle time
Lead time (LT)
The elapsed time from the time work is made available
until it’s completed and passed on to the next person or
department in the chain
aka throughput time, turnaround time, elapsed time

Value Stream Lead Time vs.
Process Time
Lead Time
Order Process Time Delivery

(Request) (Receipt)
LT = PT + Delays

Process Block Lead Time vs.
Process Time
Lead Time
Process Time
Work The time it takes Work
Received to do the work passed
to next
step
LT = PT + Delays

Key Metrics: Quality
%Complete and Accurate (%C&A)

% time downstream customer can
perform task without having to “CAC”:
Correct information or material that was
supplied
Add information that should have been
supplied
Clarify information that should have been
clear

Summary Metrics (continued)
Activity Ratio (AR)

The percentage of time work is being done to
the product passing through the process
AR = PT/LT × 100
100 – AR = Idle time
Rolled First Pass Yield (RFPY)
%C&A × %C&A × %C&A × …
Out of 100 occurrences, what percentage of
the time does the product pass through the
entire process error-free?
Future State Value Stream Map
Outpatient Imaging Services
Customer Demand: CT=Cycle Time
15 patients per Day LT=Lead Time
(Takt Time = 32 minutes) %C&A=% Complete & Accurate
8 hours per day
Cross
Standard
Training
Work
Work
Co-locate
Balance
Schedule appt
Pre-register Patient
Refer Patient
1
(Physician)
6 3 Lead Time = 45 mins. 2
Cycle T ime = 11 mins. % C&A = 85 %
Lead T ime = 45 mins.
% C&A = 98 %
Lead Time = 5 days Standard Auto Fax 80%

Risk Work Us Mail 15%
Reduction MD Mailbox 5%
(Joint Commision)
Symposium E Pay Excel Meditech Internet Fax Order PACS Rework Loop
Waiting Room
Solutions
Management via Fax 10% of
System the time
Pull System Value Stream 5S

Remove Reduce Data Voice
(Supplies Alignment
Redundant Entry Recognition
Check-in Requirements Kanban)
Set-up Continuous Standard

Standard Visual Batch
Reduction Flow Work
Work Workplace Reductions
Prep Patient, Read/Dictate Review Print Send

Check-in Conduct Exam, Exam /Sign Reports Reports
Patient T ransmit Images (Radiologist) (Radiologist) (Imaging) (Imaging)
(Imaging) (Tech)
5 mins. 60 mins. 120 mins. 6 420 mins. 7 2 mins. 8 30 mins. 9

3 4 5 2 2 2 6
2
Cycle Time = 1 mins. Cycle Time = 15 mins. Cycle T ime = 1 mins. Cycle T ime = 1 mins. Cycle T ime = 3 mins.
Cycle Time = 28 mins. % C&A = 95 % % C&A = 95 % % C&A = 99 % % C&A = 90 %
% C&A = 98 %
% C&A = 90 %
0.0833 hrs. 1 hrs. 2 hrs. 7 hrs. 0.0333 hrs. 0.5 hrs. LT = 11.4 hrs.
1 mins. 28 mins. 15 mins. 1 mins. 1 mins. 3 mins. CT = 49 mins.
CT/LT Ratio = 7.14%
Rolled First Pass
Value Stream Champion: Paul Scanner yield = 59%
Created July 20, 2005

Outpatient Imaging
Improvement Results
Projected
Metric Current State Future State % Improvement
Lead Time 32.5 hrs 11.4 hrs 65%
Process Time 56 Mins 49 Mins 13%
Activity Ratio 2.9% 7.1% 145%
RFPY 30% 59% 97%
# steps 11 8 27%
Report rework 25% 10% 60%
Tech Morale Poor Good Significant

Future State Implementation Plan
Value Stream Outpatient Imaging Implementation Plan Review Dates
Executive Sponsor Allen Ward 11/1/2007
Value Stream Champion Sally McKinsey 11/21/2007
Value Stream Mapping Facilitator Dave Parks 12/13/2007
Date Created 10/18/2007 1/10/2008
Block Implementation Schedule (weeks) Date
Goal / Objective Improvement Activity Type Owner
# 1 2 3 4 5 6 7 8 9 10 11 12 Complete
Implement standard work for referral
2 Improve quality of referral KE Sean O'Ryan
process
Reduce lead time beween schedulingand Dianne

3, 4 Cross-train and colocate work teams PROJ
preregistration steps Prichard
Eliminate the need for two patient check- Michael

5, 6 Collect copays in Imaging KE
ins O'Shea
Dianne
6 Eliminate bottleneck in waiting area Balance work / level demand KE
Prichard
Eliminate lead time associated with

9 Implement voice recognition technology PROJ Sam Parks
transcription step
10 Eliminate batched reading Reduce setup required KE Sam Parks
Reduce inventory costs, regulatory risk Michael

7 5S CT supplies area; implement kanban KE
and storage needs O'Shea
12 Reduce delay in report delivery Implement additional fax ports PROJ Martha Allen
Increase percentage of physicians

12 Reduce delay in report delivery receiving electronic delivery (rather than KE Martha Allen
hard copy)
Approvals
Executive Sponsor Value Stream Champion Value Stream Mapping Facilitator
Signature: Signature: Signature:
Date: Date: Date:

Kaizen Event – Definition
A two- to five-day focused improvement

activity during which a sequestered, cross-
functional team designs and fully
implements improvements to a defined
process or work area, generating rapid
results and learned behavior.
Karen Martin & Mike Osterling
The Kaizen Event Planner, 2007

Kaizen Events: Defining
Characteristics
Typically linked to a value stream map
Aggressive, measurable objectives
Sequestered cross-functional team (100% focus)
Short duration: 2-5 consecutive days
Professionally facilitated
Emphasis on the elimination of unnecessary non-
value-adding activities
Low cost
Define and exploit the “technical boundaries” of existing
resources
“Creativity before capital” thinking
Rapid Implementation (during the event)
Not simply planning for change

ACTION!
Examples of Healthcare
Kaizen Events
Patient flow Administrative

Imaging Payroll
Emergency Department Recruiting/hiring
Surgery process
OB/GYN Claims
Cardiac Medical Records
Ancillary services Physician
Credentialing
Lab / pathology
turnaround Space
5S Nursing areas
5S Laboratory

5-Day Kaizen: Sample Structure
Day 1 & 2 Analyze current state and

Plan perform root cause analysis;
design future state
Day 3 & 4 Design & test improvements
Do, Check using Lean tools; obtain
buy-in
Day 5 Finalize improvements; train
Check, Act process workers and
affected stakeholders;
provide closeout briefing;
CELEBRATE!

Interim Briefings to Leadership
Every day or two

Team presents their ideas; leadership assures team
has considered all options and thought through all
implications
Leadership’s role – not to say “no”
To say “Have you considered this?” “How would we
handle…?” “What if…?”
Workforce grows stronger as they learn how to
identify and eliminate waste
Leadership grows stronger as they’re able to shift
their focus to strategic planning, performance
monitoring, and coaching staff.
Kaizen Event Phases
Planning Execution
2-5 Days
4-6 Weeks Prior
Follow
Up
4-8 Weeks Post

Kaizen Event Charter
Event Scope Leadership Schedule
Value Stream Imaging
Executive Sponsor Allen Ward Dates 3/24 - 3/27/2008
Event Name Outpatient Imaging
Value Stream Start & End
Specific Conditions CT Scans Sally McKinsey 7:30 am - 4:30 pm
Champion Times
Process Trigger Referral from physician Facilitator Dave Parks Location Conference Room A
First Step Physician's office calls scheduling department Interim

Team Lead Sean Michaels Every day 3:30 - 4:30
Last Step Referring physician receives report Briefings
Workforce
3/27/2008; TBD (11 am - 1 pm)
Event Boundaries & $1,000 budget Training
Event Coordinator Ann Marie
Limitations No major program changes to Medi-Tech Team 3/27/2008
Presentation 3:30 - 4:30 pm
Event Drivers / Current State Issues Team Members
1 Losing patients to new outpatient imaging center Function Name
2 Referring physician complaints re: slow report turnaround 1
3 Patient dissatisfaction re: "hassle factor" 2
4 100% tech turnover in 6 months 3
5 4
Event Goals and Objectives 5
1 Improve quality of referral from 65% to 90% (38% improvement) 6
2 Eliminate patient check-in at Admitting 7
3 Reduce LT for report sign-off from 16 hrs to 7 hrs (65% improvement) 8
4 Reduce waiting area time from 3 hrs to 30 mins (83% improvement) 9
5 10
Potential Deliverables On-Call Support
1 Standard work for referral process / patient education piece Function Name
2 1 Radiologist practice president Marlene Diosdado
3 2 IT Jerry Gambrell
4 3 MD advisotry board pres Dave Madden
5 4
Possible Obstacles Approvals
1 Potential Joint Commission surprise audit Executive Sponsor Value Stream Champion Facilitator
2 No backup if a non-team member tech calls in sick Allen Ward Sally McKinsey Dave Parks
3 Signature: Signature: Signature:
4 Date: Date: Date:
Scoping: Refining the Focus
Nuc Med
MRI
Outpatient
CT
X-Ray
Imaging
Nuc Med
MRI
Inpatient
CR
© 2008 Karen Martin & Associates

X-Ray 25
Kaizen Event Facilitator Traits
Skills / Knowledge
Lean tools
Root cause analysis
Project & time management
Team building / facilitation
People effectiveness – from front line workers to execs
Authority / Respect
Designated change agent / influence leader
Trustworthy
Comfortable removing obstacles & reaching out to senior leadership
Personality / Energy
Challenging, yet supportive
Positive, upbeat, energetic
Pushy without irritating ☺
Objectivity / Fairness
No attachment to outcome
The Kaizen Team
The single greatest determinant of event success

No more than 10
Cross-functional composition
Process workers
Upstream suppliers (internal)
Downstream customers (internal)
Subject matter experts
Outside eyes
External suppliers / contractors
External customers
Administrative support (if needed)
Union representatives (if relevant)
Maintenance / facilities representatives
Management (limited representation)
Sequestered; Must be relieved of regular duties
Kaizen Event Phases
Planning
4-6 Weeks Prior
Execution
2-5 Days
Follow
Up
4-8 Weeks Post

Team Dynamics
Adjourning Performing
Norming
Storming
Tuckman Model
Forming Bruce Tuckman, 1965

Kaizen Commandments – “Top Twelve”
1. No interruptions from outside the Event.

2. No veto power from outside the team.
3. Rank has no privilege.
4. Abandon departmental / silo thinking.
5. Finger-pointing has no place.
6. Avoid scope creep.
7. Use creativity before capital.

Kaizen Commandments (continued)
8. Think “yes, if…” instead of “no, because…”

9. Get good data, then add experience and
“instinct” to the mix.
10. Seek the wisdom of ten rather than the
knowledge of one.
11. Keep an open mind. Challenge existing
paradigms. Challenge everything!
12. Improvements implemented today are
better than planning to implement in the
future.
Execution Phase Activities
Document the Current State Plan

Perform Root Cause Analysis
Brainstorm and Prioritize
Improvements
Design the Improvement(s) Do
Test the Design(s) Check
Finalize the Design(s) Act
Implement the Improvement(s)

Document the Current State

Brainstorm and Prioritize Improvements
Design the Improvement(s)
Test the Design(s)
Finalize the Design(s)

Current State Documentation
Tools/Activities
Go to Gemba
Spaghetti Diagrams
Calculate motion / transportation costs and
productivity losses
MBPM
Videotape
Product samples
Floor plans / blueprints
Photos
Process measurements
What to Look for at Gemba
“Waste walk”
Workplace organization
Variation in how the work is performed
Work-in-process
Quantity, oldest in queue, “problem” work, etc.
Layout
Where people are located relative to their upstream
suppliers and downstream customers
Where people, equipment, and supplies are located
relative to each other
Ergonomic concerns
Environmental issues – noise, temperature, air
quality, etc.
First, Seek to Understand: Go to Gemba
Spaghetti Diagram
Emergency Services
Waiting Area
Physician
Vitals Office Check-out
Benefits / Billing
Verification
Imaging
Exam
Patient Room
History Laboratory
ORDER CASH
The Cost of Unnecessary Motion
Distance traveled to printer

Work Group A = 92 ft. per occurrence
Work Group B = 696 ft. per occurrence
120 occurrences / day = 4,656 miles/year
Walk pace = 1 mile per hour = 582 days/year of
unproductive, non-value-adding time = 2.2 FTEs

Understand the Current State:
Metrics-Based Process Mapping (MBPM)
Future State Projected Results
Summary Metrics
Pre-Defined Performance Metrics
Current State Projected Future State Desired Direction Projected
Metric Value Units Value Units Up Down Improvement
Critical Path PT Sum 140.0 minutes 65.0 minutes 53.6%
Critical Path LT Sum 2325.0 minutes 405.0 minutes 82.6%
Activity Ratio 6.0 % 16.0 % 166.5%
Rolled First Pass Yield 23.8 % 75.3 % 217.1%
# of Activities 16 activities 8 activities 50.0%
Staffing Metrics
Current State Projected Future State Projected
Metric Value Units Value Units Change
Sum of Total PTs 155.0 minutes 65.0 minutes -58.1%
Occurrences per Year 37500 occurrences 37500 occurrences 0.0%
Staffing Requirements 46.6 FTEs 19.5 FTEs -58.1%

Test the Design(s)

Root Cause Analysis

Root Cause Analysis
Waste is a symptom.
Causes often lie very deep.
Must discover the root cause to:
Avoid band-aid fixes
PERMANENTLY eliminate the waste.

Key Root Cause Analysis Tools
Five Whys
Cause-and-Effect diagrams (aka Fishbone
or Ishikawa diagrams)
Check Sheets / Pareto Charts


Test the Design(s)

PACE Improvement Prioritization Chart
9 22 17
4 23 8 21
3
Easy
10
13
Ease of Implementation
5 1 16
15
20 14
19
6
7
11
2 18
12
Difficult
High Low
Anticipated Benefit

Test the Design(s)

Building a Lean Enterprise
Standardize
Work
Install Kanban
OK Time to Replenish

Organize the Workplace
BEFORE AFTER

Test the Design(s)
Celebrate!

Implementation = Training
Training must occur within the Kaizen

Event itself.
Therefore, it must be innovative
Stand-up sessions at the work site
Multiple offerings in a conference room
Conference call sessions
Voice mail blasts
Web-based support
Email blasts (NEVER sole training method!)
Designated mentors
54
Kaizen Event
Final Presentation Agenda
Value Stream Champion Event Name
Facilitator Event Dates

Agenda Item Presenter(s)
Opening Comments
1 • Team introductions
• Agenda
• "Rules" for attendees
Scope and Objectives
• Process being addressed
• First & last steps
2 • Specific conditions
• Event drivers / current state issues
• Objectives
• Boundaries & limitations
"Before" Condition
3 • VSM and/or MBPM review
• Relevant metrics
• Photos (if relevant)
Key Improvements Implemented
4 • Key improvements and accomplishments implemented during the event
• Tools used
"After" Condition
5 • New process description
• Projected results (direct and collateral)
Key Open Action Items
6
• 30-Day List
Sustainability Plan
7 • Potential obstacles that could prevent attaining projected performance 55
levels
Kaizen Event Phases
Planning Execution
4-6 Weeks Prior 2-5 Days
Follow
Up
4-8 Weeks Post
Sustaining Improvement
Hold weekly follow-up meetings

Full team presence highly desirable
Event Facilitator or VS Champion leads
Monitor process, refine if needed
Transition improvement oversight from Kaizen
Team to area supervision/management
Execute Sustainability Plan
Update VSM
Conduct 30-Day and 60-Day Audits
Plan to Succeed – The Sustainability Plan
58
Sustainability Plan – Page 2
59
60
Additional Questions
Karen Martin, Principal

7770 Regents Road #635
San Diego, CA 92122
(858) 677-6799
ksm@ksmartin.com

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Kaizen Events:

Achieving Rapid Improvement in

Who? Accountability Tool

Leadership “What has to happen” Value Stream

Workforce “How it will happen” Kaizen Events

© 2008 Karen Martin & Associates 4

Value Stream: All of the activities, required to

Process Process Process

© 2008 Karen Martin & Associates 5

Patient Evaluation Diagnosis

Isolated pockets of excellence =

© 2008 Karen Martin & Associates 7

Auto Fax 50%

Lead Time = 10 days

Read/Dictate Review / Sign Print Send

Rolled First Pass

Created July 19, 2005

Process time (PT)

© 2008 Karen Martin & Associates 9

Order Process Time Delivery

© 2008 Karen Martin & Associates 10

© 2008 Karen Martin & Associates 11

%Complete and Accurate (%C&A)

© 2008 Karen Martin & Associates 12

Activity Ratio (AR)

Lead Time = 5 days Standard Auto Fax 80%

Pull System Value Stream 5S

Set-up Continuous Standard

Prep Patient, Read/Dictate Review Print Send

5 mins. 60 mins. 120 mins. 6 420 mins. 7 2 mins. 8 30 mins. 9

Created July 20, 2005

© 2008 Karen Martin & Associates 15

Reduce lead time beween schedulingand Dianne

Eliminate the need for two patient check- Michael

Eliminate lead time associated with

10 Eliminate batched reading Reduce setup required KE Sam Parks

Reduce inventory costs, regulatory risk Michael

Increase percentage of physicians

Date: Date: Date:

A two- to five-day focused improvement

© 2008 Karen Martin & Associates 17

© 2008 Karen Martin & Associates 18

Patient flow Administrative

© 2008 Karen Martin & Associates 20

Day 1 & 2 Analyze current state and

© 2008 Karen Martin & Associates 21

Every day or two

© 2008 Karen Martin & Associates 23

First Step Physician's office calls scheduling department Interim

© 2008 Karen Martin & Associates

The single greatest determinant of event success

© 2008 Karen Martin & Associates 28

© 2008 Karen Martin & Associates 29

1. No interruptions from outside the Event.

© 2008 Karen Martin & Associates 30

8. Think “yes, if…” instead of “no, because…”

Document the Current State Plan

© 2008 Karen Martin & Associates 32

Document the Current State

© 2008 Karen Martin & Associates 33

Distance traveled to printer

© 2008 Karen Martin & Associates 38