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The Executive Guide to Healthcare Kaizen
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Table of Contents

The Need for Kaizen
Quick Take
Kaizen = Change for the Better
Kaizen = Meaningful Improvements
Healthcare's Opportunity for Improvement
The IOM's Recommendations for Continuous Learning
Dr. Berwick's Early Call for Kaizen in Healthcare
The Impact of Kaizen at Franciscan St. Francis
It Is Not Always about Cost
The Business Case for Kaizen
Lower Staff Turnover Costs
Cost Reductions and Hard Savings
Higher Revenue and Patient Throughput
Cost Avoidance and Soft Savings
Improved Quality and Patient Safety
Improvements Have Interwoven Results
What Executives Need to Do
Creating a Management Operating System
Tying Kaizen to Strategy
Connecting Kaizen to the Mission
Conclusion
Discussion Questions
Endnotes

What Is Kaizen?
Quick Take
Bubbles for Babies
Kaizen = Continuous Improvement
Kaizen Is Not Just Change, It Is Improvement
Kaizen Starts with Small Changes
A Small Kaizen with Great Meaning
Kaizen Involves the People Who Do the Work
Kaizen, PDSA, and the Scientific Method for Improvement
We Often Succeed as the Result of Failing More
"Failure" Should Result in Learning
Changing Back Can Be Better for Babies
Kaizen Is Not a Suggestion System-It Is an Improvement System
Common Dysfunctions of Suggestion Systems
Suggestion Boxes Are Rarely or Never Opened
Suggestion Box Systems Are Slow, with Poor Feedback
Too Many Suggestions Are Rejected or Ignored
Suggestion Systems Put the Burden on Managers
Winner Takes All Demoralizes the Rest
Suggestion Bonuses Cause More Trouble than They Are Worth
Kaizen and Lean
Kaizen: One of the Two Pillars of The Toyota Way and Lean
Respect for People = No Layoffs Due to Kaizen
Kaizen and Respect Are Intertwined
Kaizen Closes Gaps between Staff and Leaders
Kaizen Values Creativity before Capital
Kaizen Helps Avoid Expensive Mistakes
Kaizen Reignites Our Inherent Creativity
People Are the Ultimate Competitive Advantage
Conclusion
Discussion Questions
Endnotes

Types of Kaizen
Quick Take
The Continuous Improvement of a Lifesaving Innovation
Kaizen Means Continuous Improvement or Just Projects?
Three Levels of Kaizen
Large Projects
Mid-Sized Projects
Smaller, Daily Improvements
Complementary Nature of the Levels of Kaizen
Three Types of Kaizen at Children's Medical Center Dallas
Events Are Powerful, but Not Enough
Basic Structure and Format of an Improvement Event
Additional Challenges with Weeklong Events
Combining Different Types of Kaizen
Virginia Mason Medical Center
ThedaCare
Avera McKennan
Kaizen Leads to Innovation at Franciscan
Conclusion
Discussion Questions
Endnotes

Creating a Kaizen Culture
Quick Take
Everyone Is Part of the Change Culture
The Real Goal-Cultural Transformation
Kaizen Grows Skills and Abilities
Barriers to Kaizen
Resistance to Change
Lack of Time-We're Too Busy
What a Kaizen Culture Feels Like
Everyone Is Engaged
Drivers of Engagement
Everyone Is Relentlessly Searching for Opportunities to Improve
Patients and Families Are Happy
Staff and Physicians Are Engaged
The Workspace Is Clean, Orderly, and Safe
Everyone Works Together
Everything Gets Questioned
Small Successes Lead to Bigger Successes
Imai's Three Stages of a Kaizen Culture
Conclusion
Discussion Questions
Endnotes

Daily Kaizen Methods
Quick Take
Fresh Eyes Can See Waste That Hid before Your Eyes
The 5 Steps of Kaizen
Step 1: Find
Start Small
Step 2: Discuss
Say "Yes"
Coaches for Coaches
Step 3: Implement
Seven Days Grace
Step 4: Document
Quantifying Benefits When Possible
Step 5: Share
Sharing Kaizens: Kaizen Reports and the Kaizen Wall of Fame
Visual Idea Boards: Making the Entire Kaizen Visible
Idea Cards
Electronic Kaizen Systems: Making Kaizen More Broadly Visible
Advantages of an Electronic Online Database
Quick Entry and Categorization
Automatic Routing and Electronic Communication
Quick Search and Retrieval
Electronic Kaizen within Intermountain Healthcare
Electronic Kaizen at Vanderbilt
Conclusion
Discussion Questions
Endnotes

The Role of Senior Leaders in Kaizen
Quick Take
The Reluctant CEO
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
The Specific Role of Senior Leaders
Leadership and Kaizen Participation Starts at the Top
Going to the Gemba
Key Actions for Senior Leaders
Key Action 1: Communicate Expectations, Prioritize, and Set Direction
Key Action 2: Ensure Adequate Resources Are Available
Key Action 3: Sponsor a Recognition and Incentives Program
Key Action 4: Share Notable Kaizens
Key Action 5: Thank People Personally
Conclusion
Discussion Questions
Endnotes

The Role of Other Leaders in Kaizen
Quick Take
From Cop to Coach
Kaizen Requires Leaders at All Levels
Role of Middle-Level Managers
Paula's Baby Steps Lead the Way
The "Great Big Pile of Problems"
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
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
Leaders Drive Kaizen Success
Conclusion
Discussion Questions
Endnotes

Organization-Wide Kaizen Programs
Quick Take
From Helplessness to Empowerment
From One Department to the Whole Organization
Getting Started
Starting Small and Spreading Kaizen
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
Conclusion
Discussion Questions
Endnotes

Conclusion
Small Methods Lead to a Meaningful Impact
Tools and Philosophies
Building the Culture
A Minute to Learn, a Lifetime to Master
Building upon Franciscan's Success
Your Next Steps
Building a Kaizen Community
Endnotes

About the Author

Mark Graban is an author, consultant, and speaker in the field of lean healthcare. He is the author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement (2nd Edition) and co-author of Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements. Mark has worked as a consultant and coach to healthcare organizations throughout North America and Europe. He was formerly a senior fellow with the Lean Enterprise Institute and continues to serve as a faculty member. Mark is also the Chief Improvement Officer for KaiNexus, a startup software company that helps healthcare organizations manage continuous improvement efforts. Mark earned a BS in Industrial Engineering from Northwestern University and an MS in Mechanical Engineering and an MBA from MIT Sloan Leaders for Global Operations Program. Visit his website at www.MarkGaban.com and his blog at www.LeanBlog.org. Joseph E. Swartz is the Director of Business Transformation for Franciscan St. Francis Health of Indianapolis, IN. He has been leading continuous improvement efforts for 18 years, including 7 years in healthcare, and has led more than 200 Lean and Six Sigma improvement projects. Joseph is the co-author with Mark Graban of Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvement and co-author of Seeing David in the Stone and was previously an instructor at the University of Wisconsin. Joseph earned an MS in Management from Purdue University as a Karnnert Scholar for academic excellence.

Reviews

I believe that Kaizen is essentially a 'human business.' Management must meet diversified requirements of its employees, customers, stakeholders, suppliers, and its community. In this sense, the healthcare profession can probably best benefit from Kaizen because its central task is people. I am honored to write the foreword to Healthcare Kaizen by Mark Graban and Joseph Swartz.
-Masaaki Imai, author of KAIZEN and Gemba Kaizen

To get started with Kaizen, you should do the following. First, read this book. Second, ask your employees to read the book. Third, ask your employees to begin a Kaizen system. It is just that simple. You just ask, and you will get what you ask for. Just do it and learn from the process.
-Norman Bodek, author of How to do Kaizen and The Harada Method

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 J. (Bob) Brody, CEO, Franciscan St. Francis Health

At a time when many hospitals and health systems have relegated Lean to the 'Project of the Month Club', Graban and Swartz remind us of the fundamentals that help organizations keep their Lean initiatives alive and thriving. 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

Unleashing the energy and creativity of every employee to solve problems everyday should be the sole focus of every healthcare leader. Unfortunately, there are only a handful of examples where this is happening. Healthcare Kaizen provides examples of front line staff coming up with solutions to problems on their own and implementing them. 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 and author of On the Mend and Potent Medicine

In Healthcare Kaizen, Mark Graban and Joseph Swartz show us that Kaizen is more than a set of tools. What we have learned through our application of the Virginia Mason Production System is that Kaizen is a management methodology of continuous improvement that must permeate the fabric of the entire organization. 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

The healthcare industry is in the midst of truly fundamental change, and those organizations that engage their front line staff in developing the strategies for improving care, enhancing satisfaction, and streamlining processes to reduce unnecessary variation and expense will be well positioned to thrive in a post-reform environment. In their book, Healthcare Kaizen, Graban and Swartz create a roadmap for using incremental, staff driven changes to inculcate performance improvement into the culture of an organization in a sustainable manner. This book represents a wonderful resource for healthcare leaders looking to foster innovation at all levels.
Brett D. Lee, PhD, FACHE, CEO, Lake Pointe Health Network

Healthcare Kaizen
is a practical guide for senior 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. Health systems struggle to move beyond improvement work being extra work done in "special projects" facilitated by experts. This book can guide organizational transformation so that continuous improvement becomes part of the daily work of frontline staff.
-John E. Billi, MD, Associate Vice President for Medical Affairs, University of Michigan

When healthcare organizations take initial steps on their Lean journey, they often focus very heavily on tools and grand solutions, which may create new barriers to innovation. In Healthcare Kaizen, Mark and Joe remind us of the great power of daily problem solving. Their examples reinforce that learning is a result of the repeated tests of changes that are often small and simple, and less often by hitting the home runs of improvement. 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 Tetreault, MD, President and CEO, St. Boniface Hospital, Winnipeg, Canada
-Bruce Roe, MD, Chief Medical Officer, St. Boniface Hospital, Winnipeg, Canada

Without exception, the leadership of the health system is the determinant of success or failure in Lean transformation. The Executive Guide to Healthcare Kaizen is a focused and concise guide for that journey, a must-read for those who have that responsibility.
-Dave Munch, MD, Senior Vice President and Chief Clinical Officer, Healthcare Performance Partners

In the last decade, implementation of the Lean production model in a healthcare setting has produced remarkable outcomes and revolutionized the way we deliver care. Using examples from Franciscan Health and other forward-thinking medical groups, the book contains valuable strategies for organization-wide cultural transformation to create a more efficient, patient-centered healthcare system dedicated to continuous quality improvement.
-Donald W. Fisher, PhD, President and CEO, American Medical Group Association

Mark Graban and Joseph Swartz have brought to life the critical concept of kaizen - continuous improvement. In this latest edition, a great deal of emphasis is placed on senior management engagement and support of ongoing improvement. Most agree that meaningful, sustained change cannot occur without leadership from the top, engagement of the front lines, and cohesion of the leadership chain. This book does a wonderful job of delivering these important concepts in an accessible, intriguing manner. Kudos to Graban and Swartz!
-Jody Crane, MD, MBA, Senior Medical Director, Stafford Hospital; Principal, X32 Healthcare; and co-author of The Definitive Guide to Emergency Department Operational Improvement

Unfortunately the Lean movement has too often turned into a race to implement as many of the tools of Lean in as many places as possible. This is totally alien to the spirit of kaizen or the purpose of the Toyota Production System. The purpose is to create a culture of continuous improvement with people at all levels thinking deeply about their ideal vision for the people and process, and purposefully taking steps to achieve the vision. The vision should be for the good of the enterprise, not to check the box for the Lean folks who are auditing 5S and visual management.

Mark and Joe have a deep understanding of the purpose of TPS and what is needed in healthcare to raise this from a program to a true culture that can tackle all the difficult challenges that face modern medicine. He has been steeped in the healthcare field for years and has great examples to illustrate kaizen, both small and big changes. In this book he takes on the challenge of driving kaizen down to the level of every work group--truly the deepest meaning of kaizen. This takes exceptional leadership, a second nature understanding of the tools, and always working at the gemba to solve the real problems. 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 Research Award-winning author of The Toyota Way

It has been studied and shown that true north for healthcare organizations is an engaged senior leader and senior leadership team. This factor alone is the difference between mediocrity and excellence when it comes to performance and sustained extraordinary metrics for care, health and cost. The Executive Guide to Healthcare Kaizen provides a foundation for you as an executive to build the learning organization needed in today's environment. Smart, to the point, and handy. You will find this guide invaluable.
-Betty Brown, MBA MSN RN CPHQ FNAHQ, Immediate Past President of NAHQ; and Principal of ELLO Consulting, LLC

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. Its' must-have supplement, The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization, clearly outlines the role of management in leading this important work. It is not enough to be supportive; rather, one must demonstrate genuine interest with active participation and not delegate continuous improvement to others.
-Alice Lee, Vice President of Business Transformation, Beth Israel Deaconess Medical Center

For the past 7 years I have been leading a successful Lean healthcare transformation at Chugachmiut, the non-profit organization I lead in Alaska. During that time, 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, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements. Every employee can learn the tools of Lean, and improve processes as a result. However, sustaining a Lean transformation and resisting entropy requires engaging front line employees in a long term vision for serving their customers and in true continuous improvement. Employees who work in a culture that removes blame and shame, operates on facts and seeks improvement continuously have great leadership and will respond with incredible results. This book is a long needed addition to my growing Lean healthcare library.
-Patrick M. Anderson, "Lean in Alaska" Governance and Management Consulting

The term 'kaizen' has been interpreted in many ways since we learned of the Toyota Production System in healthcare. Mark and Joe demystify the term, help us understand its real meaning, and help us see how using kaizen can help us improve in healthcare and, frankly, how we can use kaizen to save lives. 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

The healthcare industry has long struggled to tap one of the biggest sources available to it for ideas to improve outcomes and reduce costs - its front-line staff. Healthcare Kaizen lays out a step-by-step approach that any healthcare organization can use to get the dramatic results that come when its workforce is fully engaged in kaizen activities on a daily basis. 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 at the University of Massachusetts; Co-author of Ideas Are Free and Corporate Creativity

What Mark Graban and Joseph Swartz have done in Healthcare Kaizen and The Executive Guide to Healthcare Kaizen is to bring hope and light to a part of our society that is facing increasing challenges. Full of examples and illustrations from hospitals and healthcare professionals leading the way in the journey to patient-centered, error-free care delivery, this book makes it easy to connect with this very powerful concept of kaizen. By putting kaizen within the broader tradition of quality improvement, shedding light on its historical development and pointing out potential pitfalls in its application in healthcare, the authors provide a great service to the healthcare community. I was especially impressed by the authors' important insights on what a kaizen culture feels like, and how people at all levels can and must engage in daily improvement. These books will be a reference on the subject for many years to come.
-Jon Miller, CEO of the Kaizen Institute

Adoption of the Lean philosophy is dead on arrival without the involvement of an organization's senior leadership. Yet, what are members of the executive suite to think when a bunch of Japanese terms coming flying past their desk? And when the leadership philosophy required is something quite different from their training and experience? Graban and Swartz help cut through all this in a presentation that is cogent, efficient, and thoughtful. Whether you are new to Lean principles or experienced in them, this book has something to offer. Even if you don't choose to take the entire Lean journey, you will receive insights and ideas that will help you get better results from your organization.
-Paul F. Levy, author of Goal Play! Leadership Lessons from the Soccer Field; and former CEO of Beth Israel Deaconess Medical Center

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