Kaizen and the Contemporary Medical Practice

The secret of getting ahead is getting started. The secret of getting started is breaking complex overwhelming tasks into small manageable tasks, and then starting on the first one.
—Mark Twain

Brief History of Suggestion Programs

The first modern employee suggestion program was reported in a British Navy journal in 1770. Before this date, a junior naval officer who offered a suggestion or contradicted a captain or admiral’s order could be punished by hanging! The first suggestion box appeared in 1880 in a Scottish shipyard. The concept was to query all employees and then reward them financially for any ideas that were implemented.

The first U.S. company to implement a company-wide employment suggestion program was the National Cash Register Company. The idea did not catch on and was soon abandoned, because those at the top of the hierarchy expected the managers to do the thinking and the workers to do what they were told.

The suggestion box became more popular during and after World War II. Now it was possible for customers to offer their ideas for improvement in the product or service. This is not Kaizen, though, because suggestions submitted in a suggestion box are initiated by patients or outsiders and are intended for others to make the changes rather than front-line employees offering ideas that can be implemented by the staff.

The first evidence of the use of suggestions seeking improvement in healthcare was published in 1915 by Frank Gilbreth, who filmed surgical procedures with the goal of eliminating waste and improving efficiency in the operating room.1 He observed that surgeons spent more time searching for instruments than actually performing the operation.

Gilbreth’s revolutionary idea was to have a surgical “caddy” to hand instruments to the surgeon, thus allowing the surgeon to focus on the patient and the operation. To show you that medicine has been and still is bogged down in the status quo and does not accept change easily, it took another 16 years for the American Medical Association to accept the caddy system as a best practice.

Next came Dr. W. Edwards Deming, considered the father of the continuous improvement method. Deming took his ideas of continuous quality improvement to Japan, where they were adopted by the Toyota manufacturing company and became famous as the Toyota Production System, or Kaizen. This, in Deming’s words, is “the process of making incremental improvement, no matter how small, and achieving the goal of eliminating all waste that adds cost without adding value.”2

Getting Started with Kaizen in Healthcare

Kaizen is arguably the best tool for easily implementing changes in the modern healthcare practice. The goal of Kaizen in healthcare, including managing responses from a suggestion box, is to make small changes that will improve the patient experience.

The more clearly the problem or the opportunity is defined, the easier it will be to solve with the available resources.

The first step is to look for opportunities to do things in a different or fresh way. In their book Seeing David in the Stone,3 authors James B. Swartz and Joseph E. Swartz studied 70 of the world’s greatest innovators, from Galileo to Edison to the founder of Federal Express. The book emphasizes that these pioneers found opportunities first and then identified the problems that needed to be overcome to take advantage of the opportunities. The-take home message is that the more clearly the problem or the opportunity is defined, the easier it will be to solve with the available resources.

For healthcare providers, the process often starts with a suggestion. Ideas often will appear as complaints or improvement ideas. Even when idea comes in as a solution, it’s best to look first at the problem to be solved. A well-defined problem statement focuses the efforts of the team and helps set the scope of the project. Problem statements must be specific and should not include solutions. For instance, a patient once noted on a comment card that he didn’t like putting his clothes on the floor in the changing room. The problem is easily stated: patients have no place to put their clothes as they change into gowns for examinations or procedures.

Kaizen in Action

Here is an example from our practice (NB). On most Fridays, we commonly performed three to five vasectomy procedures. Sterilized trays of instruments, medications, and suture material were available for each procedure. There were approximately 20 to 25 instruments on each sterile tray. However, one of the nurses noted that only four instruments—the scalpel, the ringed hemostat to grasp the vas, the Hemoclip applier, and the specialized vasectomy hemostat—were routinely used.

She suggested that we reduce the number of instruments on each tray from 20 to the four instruments that are most frequently used. The inefficiency was that too many instruments are prepared for every vasectomy when only four are generally used. However, even though in nearly all of our cases we used only four instruments, sometimes we’d have a special case that required one or more of the additional instruments. We couldn’t just eliminate those tools altogether—they needed to be available just in case they were needed. We reviewed the medical records from the last 200 vasectomies, and we found that we only needed additional instruments in four instances.

Once we have identified a problem statement, we form a small team of participants with responsibility for or knowledge of the problem. The team looks at the current situation and asks the question, “What is true today?” Then we look at the data that reflect or illuminate the problem statement.

The next step is to define the desired target state: what do we want to be true? In the case of the vasectomy trays, we wanted to have make the most frequently required instruments immediately at hand, while still having the larger selection available.

After defining the target state, it’s time to identify the gap: what keeps you from achieving the target state? Solving the problem of the instruments on the vasectomy trays was easy. We had always made all 20 instruments available. “This is the way we’ve always done it” is one of the greatest obstacles to improvement and comes up often! It’s common for the team to jump straight to solutions, but it’s important to spend time here to be sure you have developed a good list of obstacles.

Now it’s time to develop solutions. Have the team brainstorm ideas that will eliminate the issue. Once there is a good list of potential solutions, have the team choose which they want to work on. Other considerations will affect your ideas.

Develop a plan to try out each proposed solution, and then conduct a limited-scope experiment. For our vasectomy trays, we had the four most commonly used instruments open for each procedure; the remaining 16 tools were in the room, but remained in the sterile packaging. Those packages could be opened if they were needed.

Did your experiments work? Be open to the possibility of an unforeseen occurrence. With our surgery tray, we pretended we needed one of the 16 tools. When we opened the pack, we found that the paper wrapping the tray of instruments was punctured, and the pack wasn’t sterile. A compromised pack is a rare occurrence, but we decided we needed two additional packs in the room, just in case.

Setting up the procedure room, we used preference cards to detail which tools and instruments should be present. We updated the preference cards to show three packs of instruments, one with 4 instruments and the other two with 20 instruments, that would be available for each procedure. We suggest creating whatever work-aids or instructions are needed to let everyone know about the new process.

Lastly, share the results. Your team has done some great work, and they deserve to be recognized. The Kaizen Report is a great tool to let the entire practice know what the team did. Be sure the person who made the original suggestion is aware that you took action, and that his or her input was instrumental in making these improvements.

Advantages of Kaizen

Kaizen levels the playing field between management and staff. When entry-level employees see opportunity for positive change, Kaizen empowers them to become agents of change—and providing leadership encourages them to recognize needed improvement and to suggest solutions.

A successful practice is not just about clinical skills, but also about the participation of everyone in ongoing quality and process improvement.

Many practices and hospitals have an unfortunate mindset that instructs the staff only to show up on time, keep their heads down, refrain from complaining, and do the job as it is outlined in the employee manual. If leaders don’t engage the staff in improvement of their work, they waste an opportunity to improve efficiency, productivity, and patient care. A successful practice is not just about clinical skills, but also about the participation of everyone in ongoing quality and process improvement.

Bottom Line: Many practices request comments and suggestions from patients but fail to follow up. The lack of follow-up includes failure to even acknowledge and thank the patient for taking the time to submit a suggestion. This approach sends a terrible message to patients: give us your suggestions, and we will ignore them. This is one of the many examples that healthcare is in dire need of improvement. Kaizen is perhaps the best tool for closing the loop between receiving suggestions and implementing solutions. Improvement can occur at any level within practices and hospitals. Often it is the patients, employees, doctors, and staff who see the problems and have the best ideas for solving those problems. Remember, no problems are too small or big for Kaizen to solve. All it takes is to identify a problem, develop a solution, experiment, make the change permanent, and share the experience.

Reference

1.    Towill DR. Frank Gilbreth and health care delivery method study driven learning. Int J Health Care Qual Assur. 2009;22(4):417-40.

2.    Gabor A. The Man Who Discovered Quality: How W. Edwards Deming Brought the Quality Revolution to America. New York: Penguin; 1992.

3. Swartz JB, Swartz JE. Seeing David in the Stone: Find and Seize Great Opportunities. Carmel, IN: Leading Books Press; 2006.