1st Edition

Healthcare Kaizen Engaging Front-Line Staff in Sustainable Continuous Improvements

By Mark Graban, Joseph E. Swartz Copyright 2012
    404 Pages 201 Color Illustrations
    by Productivity Press

    404 Pages
    by Productivity Press

    Healthcare Kaizen focuses on the principles and methods of daily continuous improvement, or Kaizen, for healthcare professionals and organizations. Kaizen is a Japanese word that means "change for the better," as popularized by Masaaki Imai in his 1986 book Kaizen: The Key to Japan’s Competitive Success and through the books of Norman Bodek, both of whom contributed introductory material for this book.

    Winner of a 2013 Shingo Research and Professional Publication Award!

    In 1989, Dr. Donald M. Berwick, founder of the Institute for Healthcare Improvement and former administrator of the Centers for Medicare & Medicaid Services, endorsed the principles of Kaizen in the New England Journal of Medicine, describing it as "the continuous search for opportunities for all processes to get better." This book shows how to make this goal a reality.

    Healthcare Kaizen shares some of the methods used by numerous hospitals around the world, including Franciscan St. Francis Health, where co-author Joe Swartz has led these efforts. Most importantly, the book covers the management mindsets and philosophies required to make Kaizen work effectively in a hospital department or as an organization-wide program.

    All of the examples in the book were shared by leading healthcare organizations, with over 200 full-color pictures and visual illustrations of Kaizen-based improvements that were initiated by nurses, physicians, housekeepers, senior executives and other staff members at all levels.

    Healthcare Kaizen will be helpful for organizations that have embraced weeklong improvement events, but now want to follow the lead of ThedaCare, Virginia Mason Medical Center, and others who have moved beyond just doing events into a more complete management system based on Lean or the Toyota Production System.

    It’s often said, without much reflection, that people hate change. The experiences shared in this book prove that people actually love change when they are fully engaged in the process, get to make improvements that improve patient care and make their day less frustrating, and when they don’t fear being laid off as a result of their improvements.

    Mark Graban explains why his new book Healthcare Kaizen is a great resource for healthcare organizations looking to make improvements on the frontlines.(www.youtube.com/watch?v=l4JdaH03Dbo&feature=youtu.be)

    Check out a recent entry about this book on the Virginia Mason Medical Center Blog, Could this new book help drive your Lean journey? (http://virginiamasonblog.org/2012/09/05/could-this-new-book-help-drive-your-lean-journey/)

    Check out what the experts at the Franciscan St. Francis Health System have to say about Healthcare Kaizen. (http://www.youtube.com/watch?v=XcGmP5gLEPo&feature=c4-overview&list=UU7jiTxn4nkMzOE5eTbf0Upw


    Kaizen and Continuous Improvement
    Kaizen = Change for the Better
    Bubbles for Babies
    Kaizen: A Powerful Word
    Kaizen Is Not Just Change, It Is Improvement
    We Often Succeed As the Result of Failing More
    Kaizen, PDSA, and the Scientific Method for Improvement
    Changing Back Can Be Better For Babies
    Kaizen = Continuous Improvement
    Kaizen Starts with Small Changes
    A Small Kaizen with Great Meaning
    Kaizen = Engaging Everybody in Their Own Change
    Kaizen Upon Kaizen Upon Kaizen
    Kaizen Closes Gaps Between Staff and Leaders
    Creativity before Capital
    Expensive Mistakes Made without the Kaizen Mindset
    Kaizen and Lean: Related and Deeply Interconnected Concepts
    People Are the Ultimate Competitive Advantage
    High-Level Kaizen Principles—The Kaizen Mindset
    This Is Not a Suggestion System—It Is an Improvement System
    Kaizen Has an Impact on People and Performance

    The Roots and Evolution of Kaizen
    Early Suggestion Programs
    Downsides of Suggestion Box Programs
    Recovering from Taylorism
    The American Roots of Continuous Improvement—TWI and Deming
    Kaizen: One of the Two Pillars of The Toyota Way
    Masaaki Imai and the Spread of Kaizen (1986)
    Dr. Donald Berwick’s Call for Kaizen (1989)
    "Medicine’s Need for Kaizen" (1990)
    Norman Bodek and American Kaizen
    Discussion Questions

    Types of Kaizen
    The Continuous Improvement of a Lifesaving Innovation
    Three Levels of Kaizen
         Imai’s Three Levels of Kaizen
         Complementary Nature of the Levels of Kaizen
         Three Types of Kaizen at Children’s Medical Center Dallas
    Events Alone Will Not Make You Lean
         The Origins of Kaizen Events
         Basic Structure and Format of an Improvement Event
         Impressive Results from Kaizen in Healthcare
              Virginia Mason Medical Center
         Criticisms of Weeklong Events
    Not All Kaizen Organizations Rely on Events
         Kaizen Leads to Innovation at Franciscan

    Moving Toward a Kaizen Culture
    The Real Goal—Cultural Transformation
    What a Kaizen Culture Feels Like
         Everyone Is Engaged
              Drivers of Engagement
         Everyone Is Relentlessly Searching for Opportunities to Improve
         The Two Parents of Transformation: Pain and Possibility
         You Have Control over Your Workplace
         Patients and Families Are Happy
         Staff and Physicians Are Happy
         Work and Patient Care Flow Like Clockwork
         The Workspace Is Clean, Orderly, and Safe
         Everyone Works Together
         Everything Gets Questioned
         Small Successes Lead to Bigger Successes
    Small Kaizen Leads to More Big Ideas
         Bite-Size Chunks
         Imai’s Three Stages of Kaizen


    Quick and Easy Kaizen
    How to Do Kaizen
    Quick and Easy Kaizen
    Starting the Franciscan Kaizen Journey
    The Quick and Easy Kaizen Process
         Step 1—Find
              Start Small
              Start With You
              Make Your Work Easier
              Make Your Work Safer
              Make Your Work More Interesting
              Build Your Skills, Your Capabilities, and Your Knowledge
              See an Opportunity or a Problem
         Step 2—Discuss
              Discuss with your Direct Supervisor
              Discuss with Your Team Members
              Quantify the Idea
         Step 3—Implement
              Enrolling Others to Help
              Implement the Improvement Idea
              Seven Days Grace
         Step 4—Document
              Finalize the Kaizen report
              Submit Report For Approval
         Step 5—Share
              Leveraging Improvement Ideas from Others
              Sharing Kaizens

    Visual Idea Boards
    Making the Improvement Process Visible
    Setting up a Visual Idea Board
         Boards Should Be Highly Visible in the Workplace
         Boards in "Public" Settings
    Communication That Should Occur before the Visual Idea Board Is Put Up
         What Happened to the Suggestion Box?
         What Employees Can Expect
         A Communication Example
    Formats for Idea Cards
         Sticky Notes versus Structured Cards
         Idea Cards versus Suggestion Cards
         Modeling the Kaizen and PDSA Process in Writing
    Visual Idea Cards
         Suggestion or Idea
         Date Originated
         Created By
         Expected Benefits
         Input Needed From
         Implementation Steps
         Results Verified?
         New Method Standardized?
         Completion Date
    Idea Card Examples
         Staff and Patient Annoyances
         Asking for Help
         Addressing Patient Needs
         Getting Input from Others
    Other Formats of Idea Boards and Cards
         Park Nicollet’s KEEP Form
         Akron Children’s Hospital
         Seattle Children’s Hospital Pharmacy
    Visual Management of the Idea Boards
    Using Idea Cards to Coach People on Kaizen
         The Suggestion to "Be More Careful"
         Something’s Not Happening—So Don’t Forget
         Easier for Us, but Not Best for the Whole System?
    Tracking Completed Cards

    Sharing Kaizen
    Different Formats for Sharing
    The Kaizen Wall of Fame Format
    Kaizen Sharing Examples
         Making Things Better for Patients
              Supplies for Patients
              Improving Meal Rounds
         Easier to Get DVDs
         Little Details for Patients
    Preventing Mistakes or Harm
         Ensuring Proper Bed Cleaning
         Preventing Pressure Ulcers
         More Accurate Lab Results Through Standardized Work
         Proper X-Ray Ordering
         Ensuring Equipment is Ready
         Eye Protection for Lab Staff
         Preventing Aerosolized Specimens
    Making Work Easier for Staff
         Easier to Plug In Carts
         Improved Ergonomics and Specimen Quality
         Saving Sore Feet
         Better Phone Ergonomics and Productivity
         Combining Two Forms Into One
    Preventing Delays
         Faster Code STEMI Heart Attack Care
         Meds for Discharged Patients
         Getting Patients to Rooms with Less Delay
         More Timely Test Results for Rounding
         Fewer Supply Chain Delays
         Better Access to Endocrinology
    Saving Space or Cost
         Creativity over Capital in the Lab
         Company Medical Clinic Costs
         An Unnecessary Label
         Rethinking Freezer Use

    The Art of Kaizen
    Barriers to Kaizen
         Resistance to Change
         Lack of Time—We’re Too Busy
    A Model for Mobilizing Support
         Tenet 1: Respect Others
         Tenet 2: Create a Vision That Matters
         Tenet 3: Convey the Why
         Tenet 4: Connect to the Mission
         Is This About Me or Is This About the Mission?
    Working with Others Based on Their Willingness to Invest
         Strategy 1: Cocreate with Those Eager for Opportunity
              Seek Their Ideas
              Play Kaizen Catch Ball
              Reigniting Everyone’s Creativity
         Strategy 2: Sell Opportunity to Those That Are Cautious
              Seven Days Grace
              Measure Progress
         Strategy 3: Find Common Meaning with and Negotiate with Opposers
              Include Opposing Viewpoints
              Find Common Meaning
              Use Demands as a Last Resort
    Kaizen and Positive Deviance
         Rules for Leaders


    The Role of Leaders in Kaizen
    Leading to Create the Culture
         Key Actions for Leaders at All Levels
         Key Action 1: Believe In the Power of Kaizen
         Key Action 2: Participate in Kaizen
         Key Action 3: Just Ask
              Ask, Don’t Tell
         Key Action 4: Use Kaizen to Develop People
         Key Action 5: Ensure Staff Members Are Recognized and Rewarded
         Key Action 6: Share and Spread Ideas
         Key Action 7: Sell the Benefits
              It Is Not Always about Cost
    Role of Top-Level Managers
         Leadership and Kaizen Participation Starts at the Top
              Dr. John Toussaint’s Participation
              Going to the Gemba
         Kaizen Reports Are for Everybody
         Key Actions for Top-Level Managers
              Key Action 1: Communicate Expectations and Prioritize
              Key Action 2: Resource Adequately
              Key Action 3: Sponsor a Recognition and Incentives Program
              Key Action 4: Share Notable Kaizens
              Key Action 5: Thank People Personally
    Role of Middle-level Managers
         Paula’s Baby Steps Lead the Way
              The "Great Big Pile of Problems"
         Leaders Drive Kaizen Success
         The Kaizen Difference
         Key Actions for Middle-level Managers
              Key Action 1: Be the Departmental Owner and Develop Co-Owners or Coordinators
              Key Action 2: Use Departmental Meetings
              Key Action 3: Encourage Staff to Participate by Asking for Their Ideas
              Key Action 4: Create a Departmental Recognition System
              Key Action 5: Put a Tracking System in Place, If One Does Not Exist
              Key Action 6: Tie to Performance Evaluations
    Role of First-Level Managers
         A First-Level Manager Is a Coach
         Key Actions for First-Level Managers
              Key Action 1: Coach
              Key Action 2: Empower Staff—Do Not Do the Kaizen for Them
              Key Action 3: Use Rounding to Coach
              Key Action 4: Help Set Expectations
              Key Action 5: Review and Approve Kaizen Reports
              Key Action 6: Help Document Benefits
              Key Action 7: Make Kaizen Fun
              Key Action 8: Recognize and Reward
              Key Action 9: Share and Spread Ideas
              Key Action 10: Be a Cheerleader

    Organization-Wide Kaizen Programs
    Getting Started
         When Will You See Results?
         Tying Kaizen to the Organization’s Strategy
    The Kaizen Promotion Office
         Staffing the KPO
    Activities of the Kaizen Promotion Office
         Activity 1: Facilitates the Practice of Kaizen
         Activity 2: Reports Kaizen Metrics
         Activity 3: Coordinates Rewards and Recognition
         Activity 4: Facilitates Kaizen Sharing across the Organization
         Activity 5: Develops Kaizen Standardized Work
         Activity 6: Develops and Delivers Staff Education
         Activity 7: Facilitates the Documentation and Tracking of Kaizens
    Sustaining a Kaizen Program—Incentives and Rewards
         Pros and Cons of Financial Incentives
    Electronic Kaizen Systems
         Advantages of an Electronic Online Database
              Quick Entry
              Automatic Routing and Electronic Approval
              Ideas to Hold for Later
              Quick Search and Retrieval
         Electronic Kaizen within Intermountain Healthcare
         Electronic Kaizen at Park Nicollet
         Electronic Kaizen at Vanderbilt

    Lean Methods for Kaizen
    Technique 1: Add Value
         The Internal Customer’s Point of View
         Different Forms of Patient Value
    Technique 2: Eliminate Waste
         Waste 1: Transportation
         Waste 2: Overproduction
         Waste 3: Motion
         Waste 4: Defects (Errors and Rework)
         Waste 5: Waiting
         Waste 6: Inventory
         Waste 7: Overprocessing
         Waste 8: Lost Human Potential, Creativity, and Opportunities
         Seeing Waste Through Process Observation
              "Go See"
              Spaghetti Diagrams
    Technique 3: Visual Workplace
         Color Coding
         Home Locations
              Kitchen Example
    Technique 4: 5S—Workplace Organization
         S1: Sort
         S2: Set in Order
         S3: Shine
         S4: Simplify and Standardize
         S5: Sustain
    Technique 5: Workstation Design
    Technique 6: Problem Solving
         A3 Problem-Solving Technique
         Example Problem-Solving A3
         Problem-Solving Methods Used with A3
              Find the Point of the Cause
              Identify the Root Cause
    Technique 7: Error Proofing
         Fatal and Preventable Healthcare Errors
         Four Elements of a Zero Defect Quality System
              Element 1: Self-Check and Successive Check
              Element 2: Immediate Feedback and Corrective Action
              Element 3: Source Inspection
              Element 4: 100% Inspection

    Kaizen At Home
    Kaizen Tips from an Actress
    Kaizen Tips from a Behavioral Scientist
    Kaizen at Home
    Kaizen before Work
         Kaizen for Breakfast
         Kaizen to Get Ready for Work
         Kaizen with Your Coffee
         Kaizen to Get Dressed
         Kaizening Cup Clutter
         Kaizen on the Way to Work
         Kaizen in the Home Office
              Kaizen on the Computer
              Kaizen on the Physical Desktop
         Kaizen after Work
         Kaizen for Dinner
         Kaizen in the Backyard
         Kaizen Home Repair
         Kaizen for the Earth
         Kaizen in the Bathroom
         Kaizen and Your Kids
         A Vacation from Kaizen?
         Kaizen for Repetitive Tasks
         Kaizen for the Kaizen Process

    A Minute to Learn, a Lifetime to Master
    Your Next Steps
    Building a Kaizen Community

    Each chapter includes a Conclusion, Discussion Questions, and Endnotes


    Mark Graban

    Mark Graban is one of the most respected voices in the Lean world. He is the founder and driving force behind Lean Blog, (http://www.leanblog.org/blog/) a vibrant site he continuously updates with compelling information and analysis about lean in health care. Mark’s new book, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (co-authored with Joseph E. Swartz), is a must read for anyone on a Lean journey. At Virginia Mason, the concept of kaizen, which Mark and Joe write about so well in the new book, is ingrained in the organization’s cultural DNA. … The real goal of Lean in health care, they write, is cultural transformation. This is an essential insight. At Virginia Mason, the work of adapting the Toyota Production System to health care in the form of the Virginia Mason Production System has cultural transformation at its core. This sort of change is anything but easy. Culture, as the saying goes, tends to eat strategy for lunch. But cultural change is transformative.. … Mark and Joe understand the patience required to do this work well. They recognize the power of the sort of continuous incremental improvement at the heart of the Toyota Production System. … The book is highly detailed and includes helpful discussion questions at the end of each chapter.
    Virginia Mason Medical Center Blog, Could this new book help drive your Lean journey?
    Read the full review at: http://virginiamasonblog.org/2012/09/05/could-this-new-book-help-drive-your-lean-journey/

    I hope you will discover, as we have, the incredible creativity that can be derived by engaging and supporting each and every employee in improvements that they themselves lead.
    —Robert (Bob) J. Brody, CEO, Franciscan St. Francis Health

    Front line staff must know, understand, embrace and drive Kaizen and its tools to achieve incremental and continuous improvements. This book will help health care organizations around the world begin and advance their journey.
    —Gary Kaplan, MD, FACP, FACMPE, FACPE, Chairman and CEO, Virginia Mason Medical Center, and Chairman of the Board, Institute for Healthcare Improvement

    Healthcare leaders need to read this book to understand that their management role must radically change to one of supporting daily kaizen if quality safety and cost are to improve in healthcare.
    —John Toussaint, MD, CEO, ThedaCare Center for Healthcare Value

    The healthcare industry is in the midst of truly fundamental change, and those organizations that engage their front line staff … will be well positioned to thrive in a post-reform environment.
    —Brett D. Lee, PhD, FACHE, Senior Vice President, Health System Operations, Children’s Healthcare of Atlanta

    Healthcare Kaizen
    is a practical guide for healthcare leaders aspiring to engage frontline staff in true continuous improvement. Graban and Swartz skillfully illustrate how to foster and support daily continuous improvement in health care settings.
    —John E. Billi, MD, Associate Vice President for Medical Affairs, University of Michigan

    I hope everyone reads this book and recommits to the fundamentals of Lean, particularly the involvement of frontline staff in process redesign.
    —Fred Slunecka, Chief Operating Officer, Avera Health

    Kaizen has marvelously engaged so many of our staff and enabled them to improve the world around them to the benefit of staff, patients and community.
    —Paul Strange, MD, Corporate VP of Quality, Franciscan Alliance

    Mark Graban and Joseph Swartz present a clear pathway for successful Lean practice in Healthcare Kaizen. This should be on every healthcare systems reading list.
    —David Munch, MD, Senior Vice President and Chief Clinical Officer, Healthcare Performance Partners

    Mark and Joe provide real-life examples of how those who do the work provide ideas for small changes that add up to BIG results. Healthcare Kaizen is a must for leaders whose focus is the patient and how to effectively and efficiently deliver quality and safety with improved outcomes.
    —Betty Brown, MBA MSN RN CPHQ FNAHQ, President, National Association for Healthcare Quality

    Using examples from Franciscan Health and other forward-thinking medical groups, the book contains valuable strategies for organization-wide cultural transformation to create an more efficient, patient-centered healthcare system dedicated to continuous quality improvement.
    Donald W. Fisher, Ph.D., President and CEO, American Medical Group Association

    This inspirational book is packed with examples and is informed by the authors’ years of experience on the ‘front-lines’ themselves, helping leading healthcare organizations around the world to build successful kaizen programs.
    —Alan G. Robinson, PhD, Professor, Isenberg School of Management, University of Massachusetts; and Author of Ideas Are Free: How the Idea Revolution Is Liberating People and Transforming Organizations

    At Beth Israel Deaconess Medical Center, everybody improving every day is a critical aspect of our Lean and quality improvement efforts. Healthcare Kaizen, is full of relatable examples as well as practical ideas that will inspire staff, clinicians and leaders at all levels.
    —Alice Lee, Vice President, Business Transformation, Beth Israel Deaconess Medical Center

    In Healthcare Kaizen, Mark and Joe remind us of the great power of daily problem solving. The story of Franciscan St. Francis Health is compelling, where leaders created the opportunity for great people at the frontline making great improvements for patient care.
    —Michel Tétreault, MD, President and CEO, Bruce Roe, MD, Chief Medical Officer, St. Boniface Hospital, Winnipeg, Canada

    I have learned that respect for the people who work for you is key to any transformation. Mark Graban and Joseph Swartz do a great job of capturing this truth in their book… This book is a long needed addition to my growing lean healthcare library.
    —Patrick Anderson, Executive Director, Chugachmiut, Anchorage, Alaska

    The vision of a world in which our healthcare institutions operate with a universal discipline of relentless, patient-centered improvement remains a vitally important yet distant dream. In Healthcare Kaizen, Mark Graban and Joseph Swartz illustrate just how to make that dream a reality.
    —Matthew E. May, Author of The Elegant Solution and The Laws of Subtraction

    The philosophy, tools and techniques discussed in the book work, and work well, in any environment. We in healthcare must improve – we owe it to our patients and communities – and Mark and Joe are helping to show us the way.
    —Dean Bliss, Lean Improvement Advisor, Iowa Healthcare Collaborative

    What Mark Graban and Joseph Swartz have done in Healthcare Kaizen is to bring hope and light to a part of our society that is facing increasing challenges. Healthcare Kaizen will be a reference on the subject for many years to come.
    —Jon Miller, CEO, Kaizen Institute

    Hopefully this book will become a blueprint for healthcare organizations everywhere that truly want to be great!
    —Jeffrey Liker, Professor of Industrial and Operations Engineering, University of Michigan; and Shingo Prize-Winning Author of The Toyota Way

    Fixing health care may be our generation’s great test. We’ll need to engage all the good people who currently work in broken systems. Mark and Joe have helped to show us how.
    —Pascal Dennis, Lean Pathways, Inc., Author, The Remedy and Andy & Me

    Graban and Swartz present the kaizen philosophy in the most accessible way I’ve seen yet. THIS is the missing link in healthcare reform.
    —Karen Martin, Author of The Outstanding Organization and The Kaizen Event Planner

    In this new book, Graban and Swartz offer a new and innovative approach towards improving the healthcare delivery system. Unlike previous attempts by too many others, the book introduces the reader to the concept of “Kaizen”, often described as the source of Toyota’s transformation into an auto giant, acclaimed worldwide for its quality and service. The timing for the publication could not be better. … Focusing on ‘Kaizen Theory’, the book is illustratively rich in theory and applications. … The reader is introduced to concepts, tools, and exercises that foster creativity and innovation. Graban and Swartz present vivid examples to illustrate visibility, participation and accountability. … Every reader will find great value in this publication. In closing, we look forward to their next book … .
    —Miguel Burbano and Whitney Churchill, writing on www.neenan.com