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
Break apart To change

Zen
Study Make better

EVENT
Rapid Improvement
© 2008 Karen Martin & Associates

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Improvement Roles Who? Accountability Tool Strategic Leadership Middle Management “What has to happen” Value Stream Mapping / A3 Tactical Workforce “How it will happen” Kaizen Events © 2008 Karen Martin & Associates 4 .

required to satisfy a customer need from request to receipt. Value Stream Process Process Process Custom er Customer Request “Order” Customer Receipt “Delivery” © 2008 Karen Martin & Associates 5 .Value Stream Defined Value Stream: All of the activities.

Typical Healthcare Value Stream “Pre-Production” Appointment or Admission Scheduled Need Determined Start Patient Arrival / Admission Evaluation & Testing Diagnosis & Treatment Patient Discharged Patient Follow-up “Production” Payment Received Claim Submitted End “Post-Production” © 2008 Karen Martin & Associates 6 .

System Performance Systems focus = 0ptimal value stream performance Isolated pockets of excellence = sub-optimization risk © 2008 Karen Martin & Associates 7 .Individual vs.

% C&A = 100 % Cycle T ime = 11 mins. % C&A = 75 % 10 2 11 120 mins. Cycle Time = 1 mins. % C&A = 90 % 0. LT = 32. Conduct Exam. % C&A = 99 % Cycle T ime = 3 mins. % C&A = 98 % Cycle T ime = 28 mins.0833 hrs. % C&A = 95 % 16 hrs.83 hrs. 15 mins. 6 3 Lead Time = 12 mins.87% Rolled First Pass yield = 30% Value Stream Champion: Paul Scanner Created July 19. 6. 2 mins. 5 mins. 1 mins. 1 mins.Current State Value Stream Map Outpatient Imaging Services Customer Demand: 15 patients per Day (Takt Time = 32 minutes) 8 hours per day CT=Cycle Time LT=Lead Time %C&A=% Complete & Accurate Pre-register Patient Schedule Appointment 5 4 Lead T ime = 990 mins. Prep Patient. 2 110 mins. Lead Time = 990 mins.5 hrs. Print Reports (Imaging) Send Reports (Imaging) 5 3 6 2 7 8 365 mins. 2005 . % C&A = 90 % Cycle T ime = 1 mins. 1.13 hrs. % C&A = 90 % Cycle Time = 15 mins. 3 mins. 6 12 Cycle Time = 2 mins. Check-in Patient (Imaging) 80 mins.0833 hrs. % C&A = 98 % Auto Fax 50% Us Mail 25% MD Mailbox 25% Symposium E Pay Excel ADS Meditech Internet Waiting Room Management System Fax Order Solutions PACS Rework Loop via Fax 25% of the time Lead Time = 10 days Check-in Patient (Admitting) 5 mins. CT/LT Ratio = 2. 4. 2 hrs. 1. 28 mins. 5 5 mins. Transmit Images (T ech) Read/Dictate Exam (Radiologist) T ranscribe Report (MDI) 248 mins. % C&A = 95 % Cycle Time = 1 mins. Refer Patient (Physician) 2 % C&A = 65 % Patient 2 1 Cycle T ime = 30 mins. 2 Review / Sign Report (Radiologist) 960 mins. 0. 9 Lead Time = 5 mins.08 hrs.33 hrs. CT = 56 mins. Lead Time = 12 mins. 1 mins.

elapsed time © 2008 Karen Martin & Associates 9 . 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. if one is able to work on it uninterrupted Includes “think” time if process is analytical in nature aka “touch time.Key Metrics: Time Process time (PT) The time it takes to actually perform the work. turnaround time.” work time.

Value Stream Lead Time vs. Process Time Lead Time Order (Request) Process Time Delivery (Receipt) LT = PT + Delays © 2008 Karen Martin & Associates 10 .

Process Time Lead Time Process Time Work Received The time it takes to do the work LT = PT + Delays © 2008 Karen Martin & Associates Work passed to next step 11 .Process Block Lead Time vs.

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 © 2008 Karen Martin & Associates 12 .

what percentage of the time does the product pass through the entire process error-free? © 2008 Karen Martin & Associates 13 .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.

14% Rolled First Pass yield = 59% Value Stream Champion: Paul Scanner Created July 20. 1 mins. 6 9 Cycle Time = 1 mins. % C&A = 99 % Cycle T ime = 3 mins. % C&A = 95 % Cycle T ime = 1 mins. LT = 11. CT/LT Ratio = 7. 7 hrs. 1 mins. % C&A = 95 % Cycle T ime = 1 mins. 2005 . % C&A = 98 % Cycle Time = 28 mins. Conduct Exam. Cycle Time = 15 mins. 2 hrs. 1 mins. 0. 2 6 420 mins.4 hrs. % C&A = 90 % 0. 0. 15 mins. % C&A = 90 % 1 hrs. 2 8 30 mins. T ransmit Images (Tech) Read/Dictate Exam (Radiologist) Review /Sign (Radiologist) Print Reports (Imaging) Send Reports (Imaging) 3 4 2 5 120 mins.0333 hrs. 3 mins. CT = 49 mins. % C&A = 98 % Lead Time = 5 days Risk Reduction (Joint Commision) Standard Work Auto Fax 80% Us Mail 15% MD Mailbox 5% Symposium E Pay Excel Meditech Internet Waiting Room Management System Fax Order Solutions PACS Rework Loop via Fax 10% of the time Remove Redundant Check-in Reduce Data Entry Requirements Pull System (Supplies Kanban) Standard Work Set-up Reduction Value Stream Alignment Voice Recognition Continuous Flow 5S Visual Workplace Batch Reductions Standard Work Check-in Patient (Imaging) 5 mins. 2 % C&A = 85 % Cycle T ime = 11 mins. 60 mins.0833 hrs. Lead T ime = 45 mins.5 hrs. Prep Patient. 28 mins.Future State Value Stream Map Outpatient Imaging Services Customer Demand: 15 patients per Day (Takt Time = 32 minutes) 8 hours per day CT=Cycle Time LT=Lead Time %C&A=% Complete & Accurate Standard Work Work Balance Cross Training Co-locate Schedule appt Pre-register Refer Patient (Physician) 6 Patient 1 3 Lead Time = 45 mins. 2 7 2 mins.

9% 30% 11 25% Poor 11.4 hrs 49 Mins 7.Outpatient Imaging Improvement Results Metric Lead Time Process Time Activity Ratio RFPY # steps Report rework Tech Morale Projected Current State Future State 32.5 hrs 56 Mins 2.1% 59% 8 10% Good % Improvement 65% 13% 145% 97% 27% 60% Significant © 2008 Karen Martin & Associates 15 .

6 KE 6 Balance work / level demand KE 9 Implement voice recognition technology PROJ 10 Reduce setup required KE Sam Parks Michael O'Shea Martha Allen 7 5S CT supplies area. 4 Reduce lead time beween schedulingand Cross-train and colocate work teams preregistration steps Eliminate the need for two patient checkins Eliminate bottleneck in waiting area Eliminate lead time associated with transcription step Eliminate batched reading Reduce inventory costs. regulatory risk and storage needs Reduce delay in report delivery Collect copays in Imaging PROJ 5.Future State Implementation Plan Value Stream Outpatient Imaging Executive Sponsor Allen Ward Value Stream Champion Sally McKinsey Value Stream Mapping Facilitator Dave Parks Date Created 10/18/2007 Block # 2 Implementation Plan Review Dates 11/1/2007 11/21/2007 12/13/2007 1/10/2008 Implementation Schedule (weeks) 2 3 4 5 6 7 8 9 10 11 12 Date Complete Goal / Objective Improve quality of referral Improvement Activity Implement standard work for referral process Type KE Owner Sean O'Ryan Dianne Prichard Michael O'Shea Dianne Prichard Sam Parks 1 3. implement kanban KE 12 Implement additional fax ports Increase percentage of physicians receiving electronic delivery (rather than hard copy) PROJ 12 Reduce delay in report delivery KE Martha Allen Approvals Executive Sponsor Signature: Date: Signature: Date: Value Stream Champion Signature: Date: Value Stream Mapping Facilitator .

2007 © 2008 Karen Martin & Associates 17 .Kaizen Event – Definition A two.to five-day focused improvement activity during which a sequestered. Karen Martin & Mike Osterling The Kaizen Event Planner. generating rapid results and learned behavior. crossfunctional team designs and fully implements improvements to a defined process or work area.

measurable objectives Sequestered cross-functional team (100% focus) Short duration: 2-5 consecutive days Professionally facilitated Emphasis on the elimination of unnecessary nonvalue-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 © 2008 Karen Martin & Associates 18 .Kaizen Events: Defining Characteristics Typically linked to a value stream map Aggressive.

ACTION! .

Examples of Healthcare Kaizen Events Patient flow Imaging Emergency Department Surgery OB/GYN Cardiac Administrative Payroll Recruiting/hiring process Claims Medical Records Physician Credentialing Ancillary services Lab / pathology turnaround Space 5S Nursing areas 5S Laboratory © 2008 Karen Martin & Associates 20 .

design future state Design & test improvements using Lean tools.5-Day Kaizen: Sample Structure Day 1 & 2 Plan Day 3 & 4 Do. CELEBRATE! © 2008 Karen Martin & Associates 21 . train process workers and affected stakeholders. provide closeout briefing. obtain buy-in Finalize improvements. Act Analyze current state and perform root cause analysis. Check Day 5 Check.

and coaching staff. performance monitoring.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. © 2008 Karen Martin & Associates 22 .

Kaizen Event Phases Planning 4-6 Weeks Prior Execution 2-5 Days Follow Up 4-8 Weeks Post 23 © 2008 Karen Martin & Associates .

4:30 pm Event Coordinator Ann Marie Event Drivers / Current State Issues 1 Losing patients to new outpatient imaging center 2 Referring physician complaints re: slow report turnaround 3 Patient dissatisfaction re: "hassle factor" 4 100% tech turnover in 6 months 5 Function 1 2 3 4 5 6 7 8 9 10 Team Members Name Event Goals and Objectives 1 Improve quality of referral from 65% to 90% (38% improvement) 2 Eliminate patient check-in at Admitting 3 Reduce LT for report sign-off from 16 hrs to 7 hrs (65% improvement) 4 Reduce waiting area time from 3 hrs to 30 mins (83% improvement) 5 Potential Deliverables 1 Standard work for referral process / patient education piece 2 3 4 5 1 2 3 4 Function Radiologist practice president IT MD advisotry board pres On-Call Support Name Marlene Diosdado Jerry Gambrell Dave Madden Possible Obstacles 1 Potential Joint Commission surprise audit 2 No backup if a non-team member tech calls in sick 3 4 Executive Sponsor Allen Ward Signature: Date: Approvals Value Stream Champion Sally McKinsey Signature: Date: Signature: Date: Facilitator Dave Parks .000 budget Limitations No major program changes to Medi-Tech Leadership Executive Sponsor Allen Ward Value Stream Sally McKinsey Champion Facilitator Dave Parks Team Lead Sean Michaels Schedule Dates 3/24 .1 pm) Training Team 3/27/2008 Presentation 3:30 .4:30 Briefings Workforce 3/27/2008.Kaizen Event Charter Event Scope Value Stream Imaging Event Name Outpatient Imaging Specific Conditions CT Scans Process Trigger Referral from physician First Step Physician's office calls scheduling department Last Step Referring physician receives report Event Boundaries & $1. TBD (11 am .3/27/2008 Start & End 7:30 am .4:30 pm Times Location Conference Room A Interim Every day 3:30 .

Scoping: Refining the Focus Nuc Med Outpatient MRI CT X-Ray Imaging Nuc Med Inpatient MRI 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. upbeat. energetic Pushy without irritating ☺ Objectivity / Fairness No attachment to outcome © 2008 Karen Martin & Associates 26 . yet supportive Positive.

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 © 2008 Karen Martin & Associates 27 .

Kaizen Event Phases Planning 4-6 Weeks Prior Execution 2-5 Days Follow Up 4-8 Weeks Post 28 © 2008 Karen Martin & Associates .

1965 29 Forming © 2008 Karen Martin & Associates .Team Dynamics Adjourning Performing Norming Storming Tuckman Model Bruce Tuckman.

No veto power from outside the team. 6.Kaizen Commandments – “Top Twelve” 1. Finger-pointing has no place. © 2008 Karen Martin & Associates 30 . 2. 5. Rank has no privilege. 7. 3. Avoid scope creep. 4. Use creativity before capital. No interruptions from outside the Event. Abandon departmental / silo thinking.

© 2008 Karen Martin & Associates 31 . Seek the wisdom of ten rather than the knowledge of one. Improvements implemented today are better than planning to implement in the future.Kaizen Commandments (continued) 8. Challenge existing paradigms. Think “yes. Keep an open mind. Challenge everything! 12. if…” instead of “no. Get good data. 10. because…” 9. 11. then add experience and “instinct” to the mix.

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s) © 2008 Karen Martin & Associates Plan Do Check Act 32 .

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s) © 2008 Karen Martin & Associates 33 .

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 © 2008 Karen Martin & Associates 34 .

air quality. Layout Where people are located relative to their upstream suppliers and downstream customers Where people. equipment. © 2008 Karen Martin & Associates 35 . etc. etc. oldest in queue. temperature. “problem” work.What to Look for at Gemba “Waste walk” Workplace organization Variation in how the work is performed Work-in-process Quantity. and supplies are located relative to each other Ergonomic concerns Environmental issues – noise.

Seek to Understand: Go to Gemba .First.

Spaghetti Diagram Emergency Services Waiting Area Vitals Benefits Verification Imaging Exam Room Laboratory Physician Office Check-out / Billing Patient History ORDER CASH .

non-value-adding time = 2.656 miles/year Walk pace = 1 mile per hour = 582 days/year of unproductive.The Cost of Unnecessary Motion Distance traveled to printer Work Group A = 92 ft. per occurrence Work Group B = 696 ft.2 FTEs © 2008 Karen Martin & Associates 38 . per occurrence 120 occurrences / day = 4.

Understand the Current State: Metrics-Based Process Mapping (MBPM)

Future State Projected Results
Summary Metrics
Pre-Defined Performance Metrics
Current State Metric
Critical Path PT Sum Critical Path LT Sum Activity Ratio Rolled First Pass Yield # of Activities Value Units 140.0 minutes 2325.0 minutes 6.0 % 23.8 % 16 activities

Projected Future State
Value Units 65.0 minutes 405.0 minutes 16.0 % 75.3 % 8 activities

Desired Direction
Up Down

Projected Improvement
53.6% 82.6% 166.5% 217.1% 50.0%

Staffing Metrics
Current State Metric
Sum of Total PTs Occurrences per Year Staffing Requirements Value Units 155.0 minutes 37500 occurrences 46.6 FTEs

Projected Future State
Value Units 65.0 minutes 37500 occurrences 19.5 FTEs

Projected Change
-58.1% 0.0% -58.1%

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s)

© 2008 Karen Martin & Associates

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Root Cause Analysis © 2008 Karen Martin & Associates 42 .

Must discover the root cause to: Avoid band-aid fixes PERMANENTLY eliminate the waste. Causes often lie very deep. © 2008 Karen Martin & Associates 43 .Root Cause Analysis Waste is a symptom.

Key Root Cause Analysis Tools Five Whys Cause-and-Effect diagrams (aka Fishbone or Ishikawa diagrams) Check Sheets / Pareto Charts © 2008 Karen Martin & Associates 44 .

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s) © 2008 Karen Martin & Associates 45 .

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

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s) © 2008 Karen Martin & Associates 47 .

Building a Lean Enterprise .

Standardize Work .

Install Kanban OK Time to Replenish © 2008 Karen Martin & Associates 50 .

Organize the Workplace BEFORE AFTER .

Execution Phase Activities Document the Current State Perform Root Cause Analysis Brainstorm and Prioritize Improvements Design the Improvement(s) Test the Design(s) Finalize the Design(s) Implement the Improvement(s) Celebrate! © 2008 Karen Martin & Associates 52 .

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 © 2008 Karen Martin & Associates 53 .

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Kaizen Event Final Presentation Agenda Value Stream Champion Facilitator Agenda Item Opening Comments 1 • Team introductions • Agenda • "Rules" for attendees Scope and Objectives • Process being addressed • First & last steps • 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 • 30-Day List Sustainability Plan 7 • Potential obstacles that could prevent attaining projected performance levels Event Name Event Dates Presenter(s) 2 6 55 .

Kaizen Event Phases Planning 4-6 Weeks Prior Execution 2-5 Days Follow Up 4-8 Weeks Post © 2008 Karen Martin & Associates 56 .

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 © 2008 Karen Martin & Associates 57 .

Plan to Succeed – The Sustainability Plan 58 .

Sustainability Plan – Page 2 59 .

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CA 92122 (858) 677-6799 ksm@ksmartin.Additional Questions Karen Martin. Principal 7770 Regents Road #635 San Diego.com 61 © 2008 Karen Martin & Associates .

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