Modular kaizen: Dealing with Disruptions is a publication of the Public Health

Foundation, with a limited first printing in March 2011.

Suggested Citation

Bialek, R, Duffy, G, Moran, J. Modular kaizen: Dealing with Disruptions. Washington,

DC: the Public Health Foundation; 2011.

Additional Resources

To find other Quality Improvement publications, please visit the Public Health
Foundation bookstore at: http://bookstore.phf.org/

To explore free tools, resources and samples, please visit the Public Health Foundation
website at: http://www.phf.org/Pages/default.aspx

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Modular kaizen: Dealing with Disruptions
 Modular kaizen

Table of Contents

Acknowledgement ii

Preface and Overview iii

Chapter 1: The Value of Performance Management 1

Chapter 2: The House of Modular kaizen 13

Chapter 3: Implementing Performance Improvement through Modular kaizen 23

Chapter 4: A System View of the Disrupted Process 31

Chapter 5: Focus on the Disruption – Develop the Response Team 45

Chapter 6: Modular Flow for Rapid Cycle Improvement 55

Chapter 7: Tri-Metric Matrix 69

Chapter 8: Standardizing and Controlling the New System 77

Chapter 9: Change Management 91

Chapter 10: Daily Work Management: Using Quality Improvement

Skills in Daily Work 101

Appendices

Appendix A: Dr. W. Edwards Deming 111

Appendix B: Additional References 113

Appendix C: Templates and Examples 117

Appendix D: Author Biographies 133

Index 135

i
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Modular kaizen: Dealing with Disruptions
 Acknowledgements

After ten years of practicing and developing the concepts of Modular kaizen, the authors
thank the Centers for Disease Control and Prevention (CDC) for making possible the
publication of this book, supported by Cooperative Agreement Number 3U38HM000518.
The contents of this book are solely the responsibility of the authors and do not
necessarily represent the official views of CDC.

The authors are grateful to the Public Health Foundation in Washington, DC and to
Ms. Deborah Alexander, Program Administrator at the Public Health Foundation, for her
skilled editing of this book.

This book represents an important new tool that health departments can use as they work
to improve performance and outcomes under the National Public Health Improvement
Initiative (NPHII).

ii
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Modular kaizen: Dealing with Disruptions
 Preface and Overview

Dr. W. Edwards Deming, the twentieth century quality leader, is quoted as saying “A bad
system will defeat a good person every time.” 1 People who have struggled with a poorly
designed process can probably relate to that situation. The bad system grinds people
down until they no longer care about the quality of the product or service delivered to the
customer. People using a bad system take out their frustration on the customers who
complain about the poor quality that they are receiving. This destructive cycle affects
both the person using the bad process and those receiving the poor quality product or
service.

Public health budgets have taken a significant hit during the recent economic downturn,
causing a reduction in workforce and increase in workload to meet community needs.
This two-edged sword of forced change has encouraged an interruptive crisis approach to
daily work. The increasing use of mobile communications has further exacerbated this
short-term, “quickly-respond-to-crises” culture. Constantly responding to crises takes a
toll on the employees involved. Frequent crises increase employee stress levels by
constantly pulling staff away from daily work which must be accomplished to meet long-
term customer needs.

The authors have experimented with numerous quality improvement (QI) approaches to
improve working environments which generate a “bad system.” Over the years we have
encountered many different types of organizational problems. We are always intrigued
with the way organizations handle a major crisis disruption to their day-to-day
environment. The usual response is a rapid, reactive, non-data-driven approach which
usually makes the problem worse. Organizations that get into a crisis rarely take the time
to check before doing anything. Rather than spend the time to check the reality of their
current situation, they quickly take action on very limited information. Many times these
quick responses make the situation worse and harder to correct.

The authors have developed a concept called Modular kaizen to address the need for
continuous improvement within public health’s highly interruptive environment. All of
the components of an effective Kaizen event are planned; however, the activities are
scheduled in small segments that fit the rapidly changing calendar of team members and
subject matter experts. This approach is complimentary to both the Plan-Do-Check-Act
(PDCA) and Define, Measure, Analyze, Improve, Control (DMAIC) models of QI. The
basic PDCA approach, using tools designed for Modular kaizen, is introduced in Chapter
2, The House of Modular kaizen. The more robust approach based on the DMAIC
structure of Lean Six Sigma is offered in Chapter 6, Modular Flow/Rapid Cycle.

1
The Quote Garden: A Harvest of Quotes for Word Lovers. http://www.quotegarden.com/lean-
manufacturing.html. Updated February 27, 2011. Accessed May 28, 2010. Appendix A has an introduction
to Dr. W. Edwards Deming.
iii
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Modular kaizen: Dealing with Disruptions
The Modular kaizen model starts with “check” to investigate and understand the situation
to see if the disruption has a special cause or whether it is a normal variation of a standard
process. Once the disruption is identified, the Limited Information Collection Principle 2
guides data collection of performance measures to establish the severity and urgency of
the disruption, estimate who and what is impacted, and estimate the disruption timeline.
The Limited Information Collection Principle is based on the premise that a problem
cannot be solved by throwing data at it. Instead, it is important to gather information that
is useful and relevant, continually questioning “what purpose does this information
serve?” 3

The next step is “act.” Based on the data gathered in “check,” the response team does one
of the following:
 Do nothing – continue to monitor the disruption until it has either dissipated
or needs more attention. If more analysis is required, investigate by
establishing a team to investigate the disruption and report back. The report
back is in the form of a high-level scope document.
 Respond by taking short-term actions that apply all available resources to
stabilize the process. A PDCA cycle is employed to solve the disruption and
bring it under control.

In Chapter 3, Implementing Performance Management through Modular kaizen, the

beginning of this approach is documented when a major disruption hit a hospital
unexpectedly.

Modular kaizen is effectively structured to take advantage of an assessment of the eight

Lean Wastes (Table 2.1) during process improvement activities. Pre-project planning
provides a platform for identifying potential areas of waste before resources are expended
on early measurement activities. This priority setting encourages experiments designed to
identify effective data gathering based on operational feedback. Because project
milestones are often set more widely apart than normal Kaizen events, less pressure is
placed on teams to rush sampling or other observational activities during the assessment
phase.

The word Kaizen comes from the Japanese words “kai” which means change and “zen”
which means good. Today Kaizen means good change or continuous improvement
towards a standard of excellence. A traditional Kaizen event is a problem-solving
approach that requires training and facilitation to analyze and re-orient a process. The
overall concept of Kaizen is a system that encourages everyone to suggest incremental
changes, eliminating “one time” improvement events. Under Kaizen the organization is

2
Hoffherr G, Moran J, Nadler G. Breakthrough Thinking in Total Quality Management. Englewood Cliffs,
NJ: PTR Prentice Hall; 1994.
3
Hoffherr G, Moran J, Nadler G. Breakthrough Thinking in Total Quality Management. Englewood Cliffs,
NJ: PTR Prentice Hall; 1994.

iv
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Modular kaizen: Dealing with Disruptions
constantly improving. Kaizen does well in an organization that encourages and rewards
teamwork and a customer-centric culture, using daily work management at all levels to
make individual improvement.

Two of the most common uses of Kaizen are:

 Kaizen Event –a problem-solving approach that requires training and

facilitation to analyze and re-orient a process.
 Kaizen Blitz – same as an event but is focused on a short activity of two to
eight days to improve a process and requires substantial use of human
resources for this time period.
This book is about the use of Modular kaizen, defined as the improvement or redesign
project planned along a timeline that recognizes the highly volatile nature of the public
health organization’s core business processes. High-priority projects are planned at the
senior leadership level to establish realistic milestones, resources, and measurements to
ensure a return on investment that includes not only financial commitment but also the
involvement of highly skilled facilitators and subject matter experts.

Modular kaizen is not a training event but is an interactive, consultant-led, problem-

solving process that utilizes in-house subject matter experts to minimize disruption to
regularly scheduled organizational activities. The Modular kaizen flow is shown in
Figure 1.

Plan
Modular kaizen Flow
Do/
Act Disrupt

Check
check

Modular act
Do
kaizen

Plan

Figure 1: Modular kaizen improvement cycle flow

A Modular kaizen approach minimizes disruptions by making sure no “act” is executed

until “check” has been done to establish the baseline measurement of where a disruption
begins. When any action is taken, it is taken in an informed manner and is short-term in
nature. Once the disruption is fully understood, it is appropriate to charter a team to

v
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Modular kaizen: Dealing with Disruptions
develop a plan using the complete PDCA cycle that can then be implemented. This
second cycle of “check” and “act” validates (checks) the final improved outcome and acts
to document the changes for future sustainability.

This small c and a cycle is the basis of Modular kaizen, as shown in Figure 2. The
iterative nature of rapid cycle improvement, as described in Chapter 6, Modular
Flow/Rapid Cycle, is the key to sustaining and improving the integrated set of core
processes which comprise the organization as a whole.

check

act

Figure 2: Check-act iterative improvement cycle

The Modular kaizen approach minimizes disruption by making sure no “action” is

executed until “check” has been done and data has been analyzed to identify the reality of
the current situation. Modular kaizen is an approach that resists the urge to respond to a
disruption with panic. Once the process is stabilized, a full PDCA cycle is undertaken to
develop a plan and action steps to minimize the recurrence of the disruption proactively.
The final step at the end of any Modular kaizen activity is to document successes and
lessons learned. Sharing the benefit of this planned modular improvement approach to
crisis strengthens the total organizational leadership system.

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Modular kaizen: Dealing with Disruptions
 Chapter 1: The Value of Performance Management

Performance Management as a Driver for Modular kaizen activities

Performance management is the practice of actively using performance data to improve

the public’s health. This practice involves strategic use of performance measures and
standards to establish performance targets and goals. Performance management practices
can be used to prioritize and allocate resources; to inform managers about necessary
adjustments or changes in policies or programs; to frame reports on success in meeting
performance goals; and to improve the quality of public health practice. Performance
management uses a set of management and analytic processes supported by technology
that enables an organization to define strategic goals and then measure and manage
performance against those goals. Core performance management processes include goal
setting, financial planning, operational planning, consolidation of data, reporting, data
analysis, quality improvement (QI), evaluation of results, and monitoring of key
performance indicators. The focus of these performance management activities is to
ensure that goals are consistently met in an effective and efficient manner by an
organization, a department, or an employee.

Modular kaizen is an approach to help performance managers reach the goals that they
have set for their public health agency. Modular kaizen ties key performance indicators to
priority process improvement activities. Performance management maintains the ongoing
monitoring of critical operations within the organization. Strategic planning based upon
customer requirements establishes essential outcomes that define organizational success
and optimum results. Strategic business assessment on at least an annual basis provides
feedback on what outcomes are being met and where gaps are within critical outcomes.

Performance management uses both leading and lagging indicators 1 to anticipate and
track performance relative to internal and external customer requirements. The planning
and milestone design of improvement efforts reflected through Modular kaizen aligns
activities to key performance indicators which support priority outcomes of the
organization.

The Importance of Performance Management

Applying performance management techniques has measurably improved quality,

outputs, and outcomes of public health services. The coordinated efforts of performance
management strategies can impact an agency in a number of ways. Some of the ways
performance management can positively influence a public health agency include:
 better return on dollars invested in health;
 greater accountability for funding and increases in the public’s trust;

1
Bialek R, Duffy G, Moran J. The Public Health Quality Improvement Handbook. Milwaukee, WI:
Quality Press; 2009.
1
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Modular kaizen: Dealing with Disruptions Chapter 1
  reduced duplication of efforts;
 better understanding of public health accomplishments and priorities among
employees;
 partners, and the public;
 increased sense of cooperation and teamwork;
 increased emphasis on quality, rather than quantity; and
 improved problem-solving.

The Accountable Government Initiative - an Update on Our Performance Management

Agenda states that performance management efforts for 2011 are focused on six strategies
that have the highest potential for achieving meaningful performance improvement
within and across Federal agencies. 2

1. Driving agency top priorities;

2. Cutting waste;
3. Reforming contracting;
4. Closing the Information Technology gap;
5. Promoting accountability and innovation through open government;
6. Attracting and motivating top talent.

The President’s Management Council (PMC) – a group of agency deputy secretaries

chaired by Jeffrey Zients – is overseeing the effort to achieve these goals. Working with
partners in Congress, the PMC is pursuing a management agenda that embraces
technological innovations and management best practices to improve effectiveness,
efficiency, and customer service. This updated directive from 2010 gives more specific
definition to the concept of performance management than was available in previous
initiatives.

Effective PM Drives Modular kaizen Project Design

Performance management involves quantitative and qualitative measures which

accurately reflect the true achievement of operations against established standards. Health
departments are governed by local, state, regional or federal standards, based upon
legislation, funding bodies, or community objectives. These standards usually specify
outcomes such as percentage of population served, number of tests completed,
vaccinations administered, or rate of disease encountered within a representative sample.

Figure 1.1 illustrates the sequence generally employed to establish effective performance
measures for critical health department processes. The health agency senior staff
document leadership direction through mission, vision, and overall department
objectives. Based upon this operational foundation, an annual to 3-year strategic plan is

2
Zients, JD. (2010, September 14) The Accountable Government Initiative – an Update on Our
Performance Management Agenda. Memorandum for the senior executive service, Washington, DC.
2
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Modular kaizen: Dealing with Disruptions Chapter 1
generated. This strategic plan is validated based upon an assessment of needs, reflecting
customer requirements, as identified by target populations, stakeholders, community
partners, funding sources, and other priority inputs.

Once critical outcomes are identified, measures are established to monitor activities
which support the necessary outcomes related to each priority. Measures may be interim
milestones which track ongoing activities to enable long-term achievements or terminal
measures documenting the final achievement of required outcomes. The Turning Point
Model, developed by The Turning Point Performance Management National Excellence
Collaborative, 3 is an effective approach for both interim and outcome measures for
performance management within health departments.

Focus effective performance measures through alignment to

organizational objectives

Leadership
Leadership Strategic Plan Customers
Customers M
Measures
easures

•S ‐ Skills/Style •Organization Design •Needs/Profiles •Key Performance

Indicators
•W – Risks •Infrastructure •Direct interviews
•O – Opportunity •High Level Process Map •Best practices •Regulations/Standards
•T – Barriers •Org. Level SWOT •Complaints •Outcomes
(Individual)
•Industry research •Outputs
•Competitive analysis •Interim milestones
•QFD •Monitor & control
Figure 1.1: Performance Management measures must align with organizational
objectives

Performance Management Results in Public Health

According to the February 2002 Performance Management National Excellence Collabo-

rative (PMC) Survey on Performance Management Practices in States: Results of a
3
The Turning Point Performance Management National Excellence Collaborative. From Silos to Systems:
Using Performance Management to Improve the Public’s Health. Washington, DC: Public Health
Foundation; 2002.
3
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Modular kaizen: Dealing with Disruptions Chapter 1
Baseline Assessment of State Health Agencies, 4 76 percent of responding state health
agencies reported that their performance management efforts resulted in improved
performance. Most reported that performance improvement pertained to:
 improved delivery of services (program, clinical, preventive) and the ten
Essential Public Health Services;
 improved administration/management, contracting, tracking/reporting,
coordination; and
 improved policies or legislation.

More current activities continue to support the use of performance management to

prioritize and drive efficient improvements within local, state, tribal, and territorial health
departments. During the second half of the last decade, driven by the vision of Healthy
People 2010, many health departments became involved in self-assessments through
initiatives such as the National Public Health Performance Standards Program and began
identifying formal processes and measures to meet requirements set by federal, state, or
other funding organizations.

On the local level in Florida, one of the authors has been involved with the Orange
County Health Department (OCHD) since 2006 in a series of process improvement team
efforts focused on improving testing processes for sexually transmitted diseases (STD)
and immunology, reducing cycle time of Septic System Permitting and implementing an
Integrated Quality System across the total health department. A case study of the OCHD
STD 2006 project is available through the Public Health Foundation website. 5 Additional
process improvement and redesign activities were undertaken during 2008 and 2009,
using the Lean Six Sigma approach to QI. 6

The Orange County Health Department in Florida chartered a QI team to reduce total
time for administering child immunizations. Figure 1.2 is a Value Stream Map measuring
how long each major step in the immunization process took before the process was
improved. The QI team identified a number of disruptions to the process, including times
when patients’ families were waiting to be interviewed and times for children to receive
their immunizations. Note the triangle shapes, indicating that between 8 and 12 patients
were waiting at each clinic “station” during the complete flow of the process. Once the
inefficiencies in the process were identified, the QI team and the immunization nurse
manager redesigned the clinic flow. As a result, all waiting was removed. Patient time
was reduced from 33 to 4 minutes, while overall process time was reduced from 16 to 11
minutes.

4
The Turning Point National Excellence Collaborative. Turning Point Survey on Performance
Management Practices in States: Results of a Baseline Assessment of State Health Agencies. Seattle, WA:
Turning Point National Program Office at the University of Washington; 2002.
5
Public Health Foundation. Orange County Quality Improvement Project.
http://www.phf.org/programs/PMQI/Pages/Orange_County_Quality_Improvement_Project.aspx. Updated
2011. Accessed February 19, 2011.
6
Duffy G, Moran J, Riley W. Quality Function Deployment and Lean-Six Sigma Applications in Public
Health. Milwaukee, WI: Quality Press; 2010.
4
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Modular kaizen: Dealing with Disruptions Chapter 1
Additional efficiency gained through correcting inaccurate and missing client data
resolved significant disruption to the immunization team as well as to the billing
department. Reliability of information within the customer record allowed asynchronous
access to the information by billing and expedited checkout so that it could be collapsed
into the previous process step. Reducing the patient time required to go through the
immunization process increased the reputation of the clinic. Word of mouth among the
customer base encouraged more of the population to use child immunization services.

How Departments Can Use Performance Management

QI efforts are critical at all levels of the organization. Certainly the commitment of senior
management in setting and maintaining a culture of performance and quality is
imperative to long-term success. Involving the direct workforce in the identification and
resolution of performance problems on a daily basis is also imperative for effectiveness.
Line and staff management are in a good position to see both the strategic direction
coming from senior officers as well as the individual contribution of the line worker.

Medical
Records

Database

0-8 0-10 0-12

Registration Review Give Check Out &

Records Immunization Charge Sheet
8 mins 10 mins 15 mins 33 mins

5 minutes 3 minutes 3 minutes 5 minutes 16 minutes

Figure 1.2: Value Stream Map for performance of child immunization process

Some of the important contributions of middle managers in performance management

are:
 Identify aspects of the work that has and has not resulted in satisfactory results;
 Identify trends;
 Further investigate the nature of particular problems;
 Set targets for future periods;
 Motivate managers and staff to improve performance; increase their interest in
5
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Modular kaizen: Dealing with Disruptions Chapter 1
 better serving customers;
 Hold managers and staff accountable;
 Develop and improve programs and policies; and
 Help design policies and budgets and explain these to stakeholders. 7

Improving Performance is About Using Data

Performance management is the practice of actively using performance data to improve

the public’s health. This practice involves strategic use of performance measures and
standards to establish performance targets and goals. Performance management practices
can also be used to prioritize and allocate resources; to inform managers about needed
adjustments or changes in policy or program directions to meet goals; to frame reports on
the success in meeting performance goals; and to improve the quality of public health
practice.

Performance management includes the following components evident in Figure 1.3:

1. Performance standards—establishment of organizational or system
performance standards, targets, and goals to improve public health practices.
2. Performance measures—development, application, and use of performance
measures to assess achievement of such standards.
3. Reporting progress—documentation and reporting progress in meeting
standards and targets and sharing this information through feedback.
4. Quality improvement (QI)—establishment of a program or process to manage
change and achieve QI in public health policies, programs, or infrastructure based
on performance standards, measurements, and reports.

The four components of Performance Management can be applied to:

 Human Resource Development;
 Data and Information Systems;
 Customer Focus and Satisfaction;
 Financial Systems;
 Management Practices;
 Public Health Programs and Services; and
 Health Status Improvement

7
Lichiello P. Guidebook for Performance Measurement. Seattle, WA: Turning Point National Program
Office, 1999: 48. www.turningpointprogram.org/Pages/lichello.pdf - Based on Hatry HP, Fall M, Singer
TO, and Liner EB. Monitoring the Outcomes of Economic Development Programs. Washington, DC: The
Urban Institute Press; 1990.
6
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Modular kaizen: Dealing with Disruptions Chapter 1
A performance management system is the continuous use of all of the above practices so
that they are integrated into an agency’s core operations. Performance management can
be carried out at multiple levels, including the programmatic, organizational, and local,
state, tribal, and territorial levels.

Figure 1.3: Performance Management Framework and Components 8

Integrating Performance Management Techniques into Operations using

Modular kaizen

Figure 1.3 is a high-level sequence for establishing performance management. Modular

kaizen is designed to focus on the strategic priorities of the organization. Once leadership
has identified a strategic direction for the organization, properly collected customer
requirements drive the highest priority objectives. Once key objectives are known, the
next step is to set specific performance standards, targets, and goals to meet these
objectives. Development, application, and use of performance measures make it possible
to assess achievement of such standards. Measures designed to drive and assess progress
toward high-priority objectives or outcomes are called key performance indicators.

Modular kaizen depends upon the performance management system to measure the
capacity, process, or outcomes of established performance standards and targets. It is
most efficient for QI projects to use the same standards and measures which drive key

8
The Turning Point Performance Management National Excellence Collaborative. From Silos to Systems:
Using Performance Management to Improve the Public’s Health. Washington, DC: Public Health
Foundation; 2002.
7
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Modular kaizen: Dealing with Disruptions Chapter 1
priorities within the organization. This approach ensures that QI activities are most
closely aligned with the most important outcomes.

Reporting progress of improvement efforts is a critical component of Modular kaizen.

Interim reporting is crucial for communicating milestones, validating findings, verifying
assumptions, and escalating the resolution of obstacles to success. Reporting provides
formal documentation for future improvement, archival, recognition, and best practice
sharing. Reports and information should regularly be made available to managers, staff,
and others, including community partners and funding providers.

Finally, the fourth quadrant in the Turning Point model is the quality improvement (QI)
process. Modular kaizen is part of the lean family of improvement models. Lean supports
the establishment of a program or process to manage change and achieve QI in public
health policies, programs, or infrastructure based on performance standards,
measurements, and reports.

The use of QI processes emphasizes the importance of the information included in a

progress report or other document. A critical ending step for any effective QI effort is the
development of a control plan for monitoring and sustaining the gains achieved by the
improvement team. Modular kaizen uses the organization’s existing documentation
process to manage changes in policies, programs, or infrastructure based on performance
standards, measurements, and reports. If documentation processes do not yet exist for the
organization, Modular kaizen is a valid approach for creating these processes. Chapter 4,
The House of Modular kaizen, introduces a number of tools and techniques designed to
guide a QI team through establishing efficient processes for improvement, measurement,
and documentation.

Examples of the Four Components

A successful performance management system is driven by jurisdictional needs and is

designed to align closely with a public health agency’s mission and strategic plans. Public
health agencies have applied the four components in a variety of ways.

Performance Standards

Public health agencies and their partners can benefit from using national standards, state-
specific standards, benchmarks from other jurisdictions, or agency-specific targets to
define performance expectations. The National Public Health Performance Standards
Program (NPHPSP) defines performance in each of the ten Essential Public Health
Services for state and local public health systems and governing bodies. The NPHPSP
supports users of the national standards with a variety of technical assistance products,
including online data submission and an analytic report for the user jurisdiction. Some
states have developed their own performance standards for local health departments.
These state standards serve a variety of purposes, such as to provide a benchmark for
continuous QI, to determine eligibility for state subsidies, or for self-assessments in
meeting established standards.

8
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Modular kaizen: Dealing with Disruptions Chapter 1
The Public Health Accreditation Board (PHAB) has developed a national voluntary
accreditation program for state, tribal, local, and territorial health departments. The goal
of the accreditation program is to improve and protect the health of every community by
advancing the quality and performance of health departments. 9

It is important to set challenging but achievable targets. Achieving performance targets

should require concerted efforts, resources, and managerial action. If targets can be
achieved easily despite budget cuts and limited efforts, little motivation to improve
performance or to invest in additional agency efforts is generated.

Performance Measures

To select specific performance measures, public health agencies may consult national and
other sources as well as develop their own procedures to help them determine how to best
assess and measure their organizations’ performance. Performance measures typically
reflect jurisdictional needs and the feasibility of collecting the necessary data for
measurement purposes.

Reporting of Progress

How a public health agency tracks and reports progress depends upon the purposes of its
performance management system and the intended users of performance data. In Ohio,
the Department of Health publishes periodic reports on key measures identified by
Department staff, which are used by the agency for making improvements. Relevant state
and national performance indicators are reviewed by representatives of all interested
parties. Casting a wider net for reporting and accountability, the Virginia Department of
Health established resources at www.vdh.state.va.us 10 to make performance reports and
planning information accessible to policy makers, public health partners, agency
employees, and citizens.

Donabedian’s 11 assessment framework of structures, processes, and outcomes can help

public health agencies examine performance in distinct aspects of their system. An
optimal performance management approach creates feedback loops around all three
aspects. Public health performance should be managed for:
1. structures such as financial and information resources
2. processes such as health promotion and epidemiology services
3. outcomes such as health status and cost savings

For an illustration of a continuous performance feedback loop involving structural

capacity, processes, and outcomes related to public health, refer to the performance

9
Public Health Accreditation Board. www.phaboard.org. Accessed March 2, 2011.
10
Virginia Department of Health. www.vdh.state.va.us. Accessed February 28, 2011.
11
Donabedian, A. The quality of care. How can it be assessed? Journal of the American Medical
Association. 1988; 260:1743-8.
9
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Modular kaizen: Dealing with Disruptions Chapter 1
measurement model in Figure 1.4. In the model, the macro or community context of
public health translates into an integrated system of structural capacity and process
guided by the public health system’s mission and purpose. This integrated system drives
the effectiveness, efficiency, and equity of the outcomes of the local public health system.

P
U
M Structural Capacity
B
A
L Information Resources
C
I Organizational Resources
R Physical Resources
C Human Resources
O Fiscal Resources

H
C PHS Mission
E
O and Purpose
A
N
L
T Philosophy
T Goals
E
H “Core Functions”
X Outcomes
Processes
T
S Effectiveness
The 10 Essential
Y Public Health
Efficiency
Equity
S Services

T
E
M

Figure 1.4: Conceptual Framework of the Public Health System as a Basis for
Measuring Systems Performance 12

Performance management, through setting standards, identifying efficient and effective

measures, reporting progress and continuously improving based upon key performance
indicators, establishes a foundation for QI. Modular kaizen uses this performance
management system to focus on the highest impact improvements while integrating
improvement activities into the daily management of the organization. The activity-
oriented format of Modular kaizen recognizes the systemic integration of critical health
department processes while allowing for interruption of improvement efforts based upon
the priority of department outcomes. Key performance indicators are the foundation for
organizing improvement activities in tasks which can be accomplished in tandem with
daily management.

12
Handler A, Issel M, and Turnock B. A conceptual framework to measure performance of the public
health system. American Journal of Public Health. 2001, 91: 1235–1239.
10
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Modular kaizen: Dealing with Disruptions Chapter 1
Quality Improvement Process

An established QI process brings consistency to the agency’s approach to managing

performance, motivates improvement, and helps capture lessons learned. An established
QI process may focus on an aspect of performance, such as customer satisfaction, or cut
across the entire health agency. Rather than leave the use of performance data to chance,
some health departments have instituted processes to ensure that they continually take
actions to improve performance and accountability. In its highly dynamic process for
system-wide improvement, the Florida Department of Health charges its Performance
Improvement Office with coordinating resources and efforts to perform regular
performance management reviews and provide feedback to managers and local county
administrators. As part of the state’s QI process, state and local staff develop
collaborative agreements that specify what each party will do to help improve
performance in identified areas.

11
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Modular kaizen: Dealing with Disruptions Chapter 1
 12
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Modular kaizen: Dealing with Disruptions
 Chapter 2: The House of Modular kaizen

Introduction

Modular kaizen is based on the concept of Lean Enterprise 1 , which uses tools for efficient
use of resources across the whole system of interrelated processes. Traditional lean tools
grew out of the automotive and industrial sectors and over time were modified to support
service and other transactional environments. Modular kaizen modifies many of the same
tools for a highly interruptive, fast-paced workplace.

Figure 2.1 lists the major tools of Modular kaizen. These tools are designed to assess
current state performance, identify process disruptions, and reduce or eliminate any waste
which reduces the efficiency of the overall flow of operations.

Figure 2.1: The House of Modular kaizen

As shown in Figure 2.1, the foundation for any improvement effort is Change
Management. Chapter 9 describes the basic requirements for managing change. Modular
kaizen uses change management to anticipate potential change to the organization.

1
Beecroft GD. Duffy G. Moran J. The Executive Guide to Improvement and Change. Milwaukee, WI:
Quality Press; 2002.
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Modular kaizen: Dealing with Disruptions Chapter 2
Change creates an opportunity for improvement. The entry into the House of Modular
kaizen is Value Stream Mapping, the technique for identifying opportunities for
efficiency and elimination of process waste.

PDCA: Use of the Modular Plan

kaizen basic tools 2: Value stream mapping
4: Disruption identification
Act 7: Tri‐metric dashboard
7: Tri‐metric dashboard 13: Process control
13: Process control

Act Plan

Check Do

Do
Check
10: Kaizen blitz
3: 5S
Structure 11: Error proofing
5: 8‐Wastes
1: Change management 12: Quality at source
6: Force & Effect + ca
8: Teams 14: Fast transition
7: Tri‐metric dashboard
9: Project management 16: Modular flow
13: Process control
17: Daily work management

Figure 2.2: Sequence of Modular kaizen tools by PDCA phase

Figure 2.2 suggests a sequence for using the tools of Modular kaizen within the Plan–Do–
Check–Act (PDCA) cycle for process improvement. Strategic tools are used to establish
an overall structure to support PDCA activities. During the Plan phase of the PDCA
cycle, measures are used to identify any disruption to the expected process flow.
Opportunities for improvement are prioritized based upon an integrated performance
management system, tracking key objectives of the organization. Chapter 3 describes the
value of alignment to organizational priorities using performance management. The Do
phase uses tools to test improvement options for the best alternative, based upon
resources available in the time allowed. The Modular kaizen tools suggested during the
Check phase focus attention on specific areas of disruption, while performance
management again is the basis of the Act phase, where updated processes are
standardized for ongoing sustainment of efficiencies.

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Modular kaizen: Dealing with Disruptions Chapter 2
The Evolution of the House of Modular kaizen

The Modular kaizen set of tools is closely related to the traditional Lean Enterprise tool
bag. Figure 2.3 is the traditional House of Lean as described by George Alukal and
Anthony Manos. 2 The terminology describing the individual tools in the traditional
House is based upon manufacturing applications. Success using the lean tools within
manufacturing created interest by other industries in realizing the same efficiencies. Early
work by Michael George 3 using lean combined with Six Sigma tools within the service
industry encouraged many organizations to modify the initial manufacturing tools to a
broad range of industries, including healthcare, non-profit, government, and others.

Kaizen-Continuous Improvement

Pull/Kanban Cellular/Flow Total Productive Maintenance

Quality at Source Point-of-Use-Storage Quick Changeover

Standardized Work Batch Reduction Teams

Value
Stream
5S System Visual Controls Streamlined Layout Mapping

Change Management

Figure 2.3: Traditional House of Lean

The building blocks of the traditional “House of Lean” include:

Change Management: Change management is a process which helps to define the step[s
necessary to achieve a desired outcome.

Value Stream Mapping (VSM): VSM is a special type of process map that examines
flow within a process with the intent of maximizing efficiency and eliminating waste or
non-value added steps.

2
Beecroft GD. Duffy G. Moran J. The Executive Guide to Improvement and Change. Milwaukee, WI:
Quality Press; 2002.
3
George M. Lean Six Sigma for Service. New York: McGraw-Hill; 2003.
15
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Modular kaizen: Dealing with Disruptions Chapter 2
5S System: 5S is a visual method of setting the workplace in order. It is a system for
workplace organization and standardization. The five steps that go into this technique all
start with the letter S in Japanese (seiri, seiton, seison, seiketsu and shitsuke). These five
terms are loosely translated as Sort, Set in order, Shine, Standardize, and Sustain in
English. This Lean Six Sigma (LSS) tool is used often in both front and back office
applications. Clean, orderly workplaces reduce both aural and visual noise.

Visual Controls: The placement in plain view of all tooling, parts, production activities
and indicators so that everyone involved can understand the status of the system at a
glance is crucial. Labeling of storage cabinets, closets, and other workstation resources is
an example of this tool, along with diagrams of frequently performed activities for either
customers or staff.

Streamlined Layout: A workplace needs to be designed according to optimum

operational sequence. Value stream mapping is a means of representing flow of the
product or service through the process. A few of the important components of this flow
include value-added activities, non-value-added activities, non-value-added but necessary
activities, work in process (WIP), inventory (queues), processing time, and lead time.

Standardized Work: The consistent performance of a task according to prescribed

methods without waste and focused on ergonomic movement is important. Spaghetti
diagrams are a visual representation, using a continuous flow line to trace the path of a
task or activity through a process.

Batch Reduction: The best batch size is one-piece flow. If one-piece flow is not
appropriate, the batch size should be reduced to the smallest size possible.

Teams: In the lean environment, emphasis is on working in teams, whether they are
process improvement teams or daily work teams. Lean Six Sigma incorporates the use of
teams whenever possible to provide multiple perspectives for decision-making and
problem-solving.

Quality at Source: Inspection and process control by front line employees helps them to
be certain that the product or service that is passed on to the next process is of acceptable
quality. Since staffing is usually tight, having the skills readily available by more than
one person in the office saves time and provides backup within the office.

Point-of-Use-Storage: Raw material, parts, information, tools, work standards,

procedures, etc. should be stored where needed. Natural work teams within a department
often design a common work area to maximize availability of supplies and work stations
for effectiveness of staff within the office.

Quick Changeover: The ability to change staff or equipment rapidly, usually in minutes,
so that multiple products in smaller batches can be run on the same equipment is crucial.
Another common application is the consolidation of computerized data input systems so
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Modular kaizen: Dealing with Disruptions Chapter 2
that staff does not have to take one program down and bring up another to input different
forms when working with the same customer.

Pull/Kanban: This system of cascading production and delivery instructions from

downstream to upstream activities directs that the upstream supplier does not produce
until the downstream customer signals a need, using a “Kanban” system.

Cellular/Flow: Physically linking and arranging manual and machine process steps into
the most efficient combination to maximize value-added content while minimizing waste
leads to single-piece flow.

Total Productive Maintenance: This lean equipment maintenance strategy maximizes

overall equipment effectiveness. Although the title of this tool seems complex, it is really
quite simple. Every office has equipment such as copiers, printers, or shredders that
require scheduled maintenance, calibration, new release updates, etc. A preprinted
checklist or electronic reminder system for when administrative, technical, or other
programmatic updates are required minimizes downtime or lack of availability of
equipment when needed.

Figure 2.1 uses the format of the traditional House of Lean to identify the major tools
adjusted for the Modular kaizen application appropriate for highly ”interruption-driven”
organizations. Some of the tools are pulled directly from the traditional lean techniques.
Others have been slightly modified to support the modular nature of the planned
improvement steps of Modular kaizen. Change management remains the foundation for
Modular kaizen, just as it supports the traditional lean concepts. A Culture of QI requires
the adoption of change on a continuous basis to maximize resources based upon
flexibility and agility to meet customer requirements. The tool which identifies
opportunities to employ the tools of Modular kaizen is also consistent with traditional
lean concepts. Value Stream Mapping, as follow-on to flowcharting and process-
mapping, remains a robust vehicle for identifying disruptions and opportunities for
improvement within existing processes or those under initial design.

The tools within the House of Modular kaizen are:

1. Change Management: A process which helps to define the steps necessary to
achieve a desired outcome.
2. Value Stream Mapping (VSM): A special type of process map that examines
flow within a process with the intent of maximizing efficiency and eliminating
waste of non-value added steps.
3. 5S System: A visual method of setting the workplace in order. The use of 5S is
no different under the concept of Modular kaizen or traditional lean. Although
first documented for organizational effectiveness within manufacturing and
assembly operations, 5S is successfully used in health department, hospitals, front
offices of small businesses, non-profits, and organizations of all types. Some
simple examples of each of the five organizing activities are:
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Modular kaizen: Dealing with Disruptions Chapter 2
 a. Sort – Separate items, documents, or ideas. Distinguish the necessary
from the unnecessary. Get rid of what no longer holds value. Free up
space for other materials and ideas that support the organization more
effectively.
b. Straighten – “A place for everything and everything in its place” is
applicable for this step. Pegboards with locations clearly marked in a
home garage or workshop, the numbering and proper placement of books
in a library, or organization of the supply cabinet in the office so that it is
neat and easy to use would exemplify the result of straightening.
c. Shine – Tidying the copier room, washing and waxing the reception area,
keeping oil and grease off of the automobile service bay floor, or keeping
equipment clean in the laboratory exemplify this step.
d. Standardize – It is helpful to have as few different ways to perform
frequent activities as possible. Monitor and maintain the first three S’s.
Standardized processes, workflows, documentation and equipment, where
possible, simplify the workplace. This element facilitates cross-training,
providing backup for tasks and minimizing work procedures.
e. Sustain – Exert the discipline to stick to the 5S procedures for the long-
term. Set a schedule to Sort, Straighten, Shine, Standardize and Sustain so
that this iterative set of activities perpetually re-invigorates the workplace
and the staff who populate it. Clean, orderly workplaces reduce noise, both
aural and visual.

5S can be instituted in any location. An environmental health department used 5S

to:
 Sort in-process applications for Septic System Permits;
 Set-in-Order all applications by placing them in “Green Folders” for visual
recognition;
 Shine the desks and work areas, thereby locating all “lost” in-process
applications that were causing the average turn-around time for processing
to be extended;
 Standardize the Septic System Permit application process by flowcharting
and documenting the steps for consistency and ease of training new
employees; and
 Sustain the process by including measures and review points for the
office’s senior coordinator and first-line supervisor.

4. Disruption identification: Identifying the places where work is interrupted or

where the process breaks down provides excellent opportunities for improvement.
Disruptions identify either organizational bottlenecks or specific breaks in the
flow of daily operations and procedures that waste time or other resources.
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Modular kaizen: Dealing with Disruptions Chapter 2
 5. 8 Wastes: If an activity consumes resource time or capital but does not add value,
it must be wasteful and should be eliminated. The idea is to eliminate as many of
these wastes as possible in daily work activities. Removing waste makes
additional time and resources available for higher priority outcomes of the
department. An explanation of the Eight Types of Waste is shown in Table 2.1.
6. Force & Effect + ca: The Force & Effect Chart is designed to identify barriers to
agreement among team members concerning a specific situation. Once barriers
are identified, Check and Act (c + a) phases of the improvement cycle are used to
resolve disruptions and return stable operation.
7. Tri-metric dashboard: The Tri-metric dashboard helps the decision maker
measure important aspects of a process’s capacity, process capability, and
outcomes.
8. Teams: In the lean environment, the emphasis is on working in teams, whether
they are process improvement teams or daily work teams. Modular kaizen
employs teams not only for the traditional purposes but also for backup when
subject matter experts are interrupted from their improvement efforts to address
other key business priorities.
9. Project management: This tool involves all activities associated with planning,
scheduling, and controlling projects. Good project management ensures that an
organization’s resources are used efficiently and effectively. 4
10. Kaizen blitz: Kaizens, or blitzes, are improvement events where people work
only on improvement for a few days, up to a full week. In a traditional Kaizen
project, the people from a particular work area come together with a few experts
for four or five consecutive days and complete most or all of a Define-Measure-
Analyze-Improve-Control (DMAIC) cycle on a narrowly targeted, high-priority
issue. The model has been so successful that this basic approach has been adapted
to other uses such as service design sessions.
11. Error proofing: Error-proofing refers to the implementation of failsafe
mechanisms to prevent a process from producing defects.
12. Quality at source: Inspection and process control by front-line employees
ensures that the product or service that is passed on to the next process is of
acceptable quality. Since staffing is usually tight, having the skills readily
available by more than one person in the office saves time and provides backup
within the office.

4
Evans J, Lindsay W. The Management and Control of Quality, 6th Ed. Mason, OH: Thomson
Southwestern; 2005.
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Modular kaizen: Dealing with Disruptions Chapter 2
 Waste Description Public Health Example
Over- Spending more time than Combining customer survey
processing necessary to produce the product instruments into one form rather
or service. than developing specific
instruments for each program.

Transportation Unnecessary movement of Department vehicles stored in

Handling materials or double handling. central facility, requiring constant
movement of vehicles to and from
other high- traffic locations.

Unnecessary Extra steps taken by employees Immunology testing equipment

Motion and equipment to accommodate stored in cabinets far from
inefficient process layouts. specialist work area.

Unnecessary Any excess inventory that is not Overestimating vaccination

Inventory directly required for the current support materials, requiring
customer’s order. additional locked storage cases,
inventory counting, and
reconciliation.
Waiting Periods of inactivity in a Paperwork waiting for
downstream process that occur management signature or review.
because an upstream activity
does not produce or deliver on
time.
Defects Errors produced during a service Ineffective scripts for initial intake
transaction or while developing a applications. Unclear directions
product. for filling out required forms.

Overproduction Items produced in excess Insurance filing or immunization

quantity and products made record opened before all required
before the customer needs them. information is received.

People Not fully using people’s abilities Poor job design, ineffective
(mental, creative, skills, process design within business
experience, and so on) functions, lack of empowerment,
under/overutilization of maintaining a staffing complement
resources. not in balance with workload
demand.
Table 2.1: Eight Types of Wastes

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Modular kaizen: Dealing with Disruptions Chapter 2
 13. Process control: This tool is used to monitor, control, and improve process
performance over time by studying variation and its source. Modular kaizen uses
a combination of run, control, and Paynter Charts to track and represent process
performance visually.
14. Fast transition: This tool is translated from Quick Changeover in a production to
a service environment by providing cross training for staff to allow quick
movement from one project or customer requirement to another within a small
office.
15. Pull technology: This system of cascading procedures and instructions from
downstream to upstream activities ensures that the upstream supplier does not
perform activity related to a specific transaction or service until the downstream
customer signals a need.
16. Modular flow: Organizations often empower an improvement team of cross-
functional clerical staff, specialists, and management to create a seamless
sequence of steps from customer application through processing to delivery and
final review. Modular kaizen designs these sequenced steps into segments that can
be efficiently performed within the time frames allowed by a highly interruptive
workplace.
17. Daily work management: The utilization of the tools and techniques of quality
improvement (QI) in day-to-day work activities by those doing the work is
crucial. Daily work management puts control and change at the lowest level
possible within the organization. QI in daily work is called “daily work
management” (DWM) because it uses the tools and techniques of QI to make
daily work better, more customer-focused, and more manageable.

Use of the tools contained within the House of Modular kaizen is not limited to the
PDCA phase in which they are listed in Figure 2.2. Although the tools strongly support
the phase identified, in Figure 2.2, like all tools, they are to be used when conditions are
appropriate. A subsequent chapter suggests the sequence of tool usage under the DMAIC
cycle of lean Six Sigma. Modular kaizen facilitates designing and implementing process
improvement activities in a series of tasks which can be accomplished within the normal
work flow of assigned team members and subject matter experts.

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 22
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Modular kaizen: Dealing with Disruptions
 Chapter 3: Implementing Performance Improvement through Modular kaizen

Modular kaizen supports performance improvement across a timeline that recognizes the
highly volatile nature of core business processes. The pace of business has increased
rapidly over recent years. No longer can leadership rip critical resources away from front
line operations to focus on parallel improvement efforts. Improvement activities must be
integrated into existing workloads, using scarce resources when they are most available.

Modular kaizen is driven by the existing key performance measures established

throughout the organization. Where measures are not yet identified, Modular kaizen
techniques identify metrics supporting top priorities for customer service and internal
efficiencies. Pre-project planning identifies priority areas of improvement for rapid
results. By using the performance measurement system already integrated into daily
operations, process improvement activities are targeted on effective outcomes and
ongoing reduction of waste. Existing technology and information system resources are
exploited as much as possible, while identifying potential areas for consolidation of data
systems and improved functionality.

The inclusive nature of a Modular kaizen team addresses the needs of both internal and
external customers. Since project milestones may be set more widely apart than normal
Kaizen events, less pressure is placed on teams to rush sampling or other activities during
the assessment phase. Analysis and decision-making are data-driven, using both interim
and outcome effectiveness measures. Milestone reviews are built into the Modular kaizen
timeline for senior management approval and adjustment. Project documentation creates
an archive of empirical evidence to be shared with other agencies and public health
system partners.

Modular kaizen is not a training event but is a hands-on, facilitator-led, problem-solving

process that utilizes in-house subject matter experts to customize the improvement effort
and develop exacting performance evaluation instruments. Highly visible Modular kaizen
improvement efforts draw and retain top talent through challenging involvement with
critical processes. Margaret J. Wheatley, bestselling author and researcher of living
systems within human organizations, writes;

“I don’t believe that organizations are ever changed by imposing a model

developed elsewhere. So little transfers to, or inspires, those trying to work at
change in their own organization. In every organization, we need to look
internally, to see one another as the critical resources on this voyage of
discovery.” 1

Off-the-shelf improvement models are rarely effective tools for successful operational
implementation. Improvement must be based upon the needs of the specific organization.
1
Wheatley M. Leadership and the New Science – Discovering Order in a Chaotic World, 2nd Ed. San
Francisco, CA: Berrett-Koehler Publishers, Inc; 1999.
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Modular kaizen: Dealing with Disruptions Chapter 3
Modular kaizen is a concept within the family of Kaizen approaches that recognizes the
reality of the environment and culture in which organizations function. Each organization
evolves as a result of decisions made by leaders as they:
 define the strategic plan;
 identify target customer populations;
 develop core processes;
 identify areas to cut waste; and
 establish performance measures.

The hands-on facilitated performance improvement cycle involves management and staff
at all levels of the organization. Since no two organizations are exactly the same, each
Modular kaizen event varies depending on culture, leadership, and critical performance
requirements. Modular kaizen design teams may be comprised of internal personnel,
subject matter experts, customers, cross-functional partners/agencies or others familiar
with the process targeted for improvement. Since each Modular kaizen project is
customized to address top organizational goals, the use of skilled contract resources is
usually well within the scope of regulatory limitations.

A traditional Kaizen event is a problem-solving approach that requires training and

facilitation to analyze and re-orient a process. The overall concept of Kaizen is a system
that encourages everyone to suggest incremental changes. No “one time” event to
improve occurs. Under Kaizen the organization is constantly improving. Kaizen does
well in an organization that encourages and rewards teamwork and a customer-centric
culture, using daily work management at all levels to make individual improvement.

Most Kaizen improvements are designed as fast-track events which pull leaders and
subject matter experts out of the day-to-day activities to focus solely on the desired result.
More recently, the quality community has put even more focus on separating the
improvement activity from daily operations by initiating the Kaizen Blitz, which is the
same as a Kaizen event but is focused on a short spurt of between two and eight days to
improve a process. The Blitz requires substantial use of human resources for this time
period. The Blitz configuration totally removes the strongest members of the organization
for the duration of the improvement effort.

Modular kaizen is a modification of the traditional Kaizen improvement process,

designed to provide the same rapid results without removing critical personnel from daily
operations. Modular kaizen uses a step-function approach by breaking the improvement
cycle into blocks of action plans and tasks which support the highly interruptive
environment of today’s organization. Effective use of data, leadership, and
communication provide ongoing accountability so that tasks are initiated or paused
without losing improvement gains. Existing resources are coordinated with other top
priority programs, seeking to maximize effectiveness while eliminating waste.
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Modular kaizen: Dealing with Disruptions Chapter 3
If an organization can improve from the inside by changing processes, reducing waste,
and improving efficiency, capacity, and quality, it will be in a better position to absorb
the change and continue to do business. As quality improves, disruptions to the system
are reduced. As efficiency improves, the ability to satisfy customers improves. As
resources are more efficiently used, costs can be kept under control.

Bringing a Quality Improvement (QI) philosophy to an organization takes time. It

requires building a culture that says, “Everyone, everywhere in the organization, will
improve every day.” Leadership, creative thinking, and problem solving must occur at all
levels. All stakeholders must understand why something is done, what services the
organization provides, and how they can best deliver those services. Training in the tools
and techniques of lean are necessary. A change in culture requires a change in the
underlying organizational processes since culture follows process.

It sounds like a daunting undertaking, but when an organization gets involved in

improvement and change, momentum starts to build, and everyone in the organization
can see the weaknesses in the processes and are equipped and empowered to correct
them. Then, an organization can make quantum leaps in quality, efficiency,
customer/client access, and staff satisfaction. Customers are happier and more satisfied.
Employees are freed from mundane and wasteful tasks and can spend more time
performing vital functions and serving their customers. Overall, financial statements and
overall performance improve substantially.

The tools of QI are easy to learn. It is one of the best features of QI. With a little training,
everyone can apply these tools. Once people are taught how to see the waste in a process,
they will see it everywhere. The challenge is to apply leadership, priorities, and resources
to the identified problems to ensure that the right tools are used to find and fix the root
cause of a problem and then organize the work to eliminate the problem.

Two of the most common uses of Kaizen are:

 Kaizen Event –a problem-solving approach that requires training and

facilitation to analyze and re-orient a process.
 Kaizen Blitz – same as an event but focused on a short period of two to eight
days to improve a process, requiring substantial use of human resources.
This book is about the use of Modular kaizen. Modular kaizen is defined as the
improvement or redesign project planned along a timeline that recognizes the highly
volatile nature of the customer’s core business processes. High-priority projects are
planned at the senior leadership level to establish realistic milestones, resources, and
measurements to ensure a return on investment that includes not only financial
commitment but also the involvement of highly skilled facilitators and subject matter
experts.

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Modular kaizen: Dealing with Disruptions Chapter 3
Modular kaizen is effectively structured to take advantage of an assessment of the eight
Lean Wastes during process improvement activities. Pre-project planning provides a
platform for identifying potential areas of waste before resources are expended on early
measurement activities. We focus on the Limited Information Collection Principle 2 to
determine where the most likely areas are located for waste reduction. This priority
setting of tasks encourages experiments designed to identify effective data gathering
based on operational feedback.

Modular kaizen is not a training event but is instead an interactive, consultant/facilitator-

led, problem-solving process that utilizes in-house subject matter experts using the
Modular kaizen model shown below in Figure 3.1.

Plan
Modular kaizen Flow
Do/
Act Disrupt

Check
check

Modular act
Do
kaizen

Plan
Figure 3.1: Modular kaizen flow

The Modular kaizen model starts with Check where it is crucial to investigate and
understand the disruption and see if it has a special cause, understand what the
severity/urgency is, estimate who/what is impacted, estimate the length of the disruption
timeline and use the Limited Information Collection Principle to guide data collection.

The next step is Act. Based on the data gathered in Check, the response team would:

1. Do nothing – continue to monitor the disruption until they feel it has either
dissipated or needs more attention. If more attention is needed, then establishing
an investigative team to analyze the disruption and report back is important. The
report back would be a high- level scope document.

2
Hoffherr G, Moran J, and Nadler, G. Breakthrough Thinking In Total Quality Management.
Englewood Cliffs, NJ: PTR Prentice Hall; 1994.
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Modular kaizen: Dealing with Disruptions Chapter 3
 2. Respond by taking short-term actions to stabilize the process while the team
allocates time to use the PDCA Cycle to solve the problem and bring the process
back under control.

After the Do phase of the PDCA Cycle, it is time to evaluate and determine when
disruption is under control. Resources can now be returned to departments to resume
regular activities. This action is represented by the green line on the model shown in
Figure 3.1. At this point, the team documents lessons learned, knowledge gained, and any
surprising results that emerged. It is important to continue to monitor activities and hold
the gains so that the disruption remains under control.

If the disruption is not under control, activity follows the red line in Figure 3.1. The
improvement team must modify the approach taken or repeat the Plan/Do phase to make
new improvements and then check to see how the disruption responds to the new
approach.

A Modular kaizen example:

One day in the early morning hours in July 2001, a major power outage happened in a
major city, and it impacted a hospital that was filled with patients, an active operating
room with a full schedule, and a rehabilitation unit that was filled to capacity. The
temperature that day was expected to reach 98 degrees. First reports were that power
would not be returned to service for a week.

The senior staff quickly assembled at 6:30 AM. Rather than going into a panicked
planning mode, they calmly realized that this was an unplanned disruption to their
regularly scheduled activities.

The first thing that they did was “Check.” What was the real status of the power outage
and what were the conditions within the hospital? The president of the hospital called the
mayor and president of the utility company to explain the immediate needs of the
hospital. It was explained to the president of the utility company that a press conference
with the mayor was scheduled at the hospital at 9:00 AM. He was invited to attend to
explain why the hospital would have to close for a week. Board members were notified to
see where they could put pressure on the system to get the power on and what recourse
the hospital may have to recover any losses. Again, no action was taken; they simply
“Checked” to see what leverage resources were available.

The medical and nursing staff did a “Check” on patient status to determine who could
withstand a temperature increase and who could not. Those patients who could not would
be transferred. What surgeries could be postponed and which ones had to happen? What
rehabilitation activities could take place and what should be postponed if power could not
be restored?

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Modular kaizen: Dealing with Disruptions Chapter 3
The maintenance staff did a “Check” on the status of the standby generators, secured
regular fuel deliveries, and had the in-house electrical system checked to ensure that no
potential problems occurred. In addition, they developed a power diagram to show what
systems could be handled on internal generators and what would stay down.

Housekeeping “Checked” on how many sizes and types of fans were available. Then they
deployed and acquired additional large fans to keep the air moving throughout the
hospital.

A patient letter was developed by public relations and distributed to all patients, staff, and
relatives explaining the situation. Nursing staff checked in regularly with patients to keep
them informed.

These various activities occurred between 6:00 and 9:00 AM. At the press conference,
the utility president stated that he would have a large mobile generator at the hospital by
12:00 PM; it was 200 miles away. The mayor called the governor and had a state police
escort arranged to transport it more quickly, if possible. The mayor would have all of the
roads open when it reached the city limits so that it could move through any potential
traffic backups without any delays. The hospital senior staff “Checked” first, understood
what they were facing, and then did small “Act” steps to make short-term responses that
were grounded in fact and not emotion.

check
Many small
repeat cycles of
act
check and act

Figure 3.2: The check/act repeating improvement cycle

After the 9:00 AM press conference, “check” of Modular kaizen went back into effect.
From each of the checks, small actions were taken to stabilize the situation and make the
hospital ready for additional generator power. This process is shown in Figure 3.2.

First, maintenance worked with the utility company to determine where the generator
would be located and how it would hook in. They determined that a new box was
required, and it was installed before the generator arrived. They measured and decided
how long a feed was required to reach the new box and what fuel was required. A truck
was on site at 11:00 AM, ready to fuel the generator. The utility company and
maintenance staff checked the hospital electric distribution system to look for potential
failure areas when the new generator was turned on. What could potentially fail was
pinpointed, and a fix was determined and ready to go. The hospital leaders understood
what they were facing and did “Act” as appropriate to rectify problems that could arise
when the generator was being hooked up and power would be transmitted.
28
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Modular kaizen: Dealing with Disruptions Chapter 3
Leaders then conducted a temperature check, and it was up to 80 degrees. More fans
were acquired and deployed; window shades were shut. At 10:30 AM a few elderly
patients were transferred to a sister hospital because they needed a cooler environment.

By 11:00 AM, the temperature was still in the bearable 80 degree range. The generator
arrived at 12:00 PM and was ready to transmit power at 12:30 PM. By 2:00 PM the
temperature was decreasing, and by 5:00 PM it was cool in the hospital.

This situation lasted for three more days, but panic did not ensue. Constant check was the
rule throughout this crisis with no panicked planning or arbitrary actions taken. Out of
each check came a logical small action plan which was executed. If further follow-up was
required, it was acted upon. Staff continued their regular routine in the hospital with
occasional update meetings, causing a disruption to their regular schedule. Subject matter
experts were called upon as necessary and again they could resume their regular routine
with minor interruptions. The hospital operated in a normal mode with a major disruption
occurring because they Checked before Acting.

A Modular kaizen approach minimized the disruption and made sure that no “action” was
executed until “check” had been done to establish the beginning point. Once the situation
stabilized, the senior staff did a full PDCA cycle, documenting lessons learned and
making plans to ensure that if this situation or crisis impacting the hospital happened
again, actions could be taken in advance to minimize the situation.

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Modular kaizen: Dealing with Disruptions Chapter 3
 30
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Modular kaizen: Dealing with Disruptions
 Chapter 4: A System View of the Disrupted Process

Introduction

An organization is a system of activities composed of a web of regularly occurring inter-

relationships. A system dovetails and drives excellence across the organization. This
system of inter-relationships has common patterns, behaviors, and properties that can be
understood through measurement. Measurement is used to develop greater insight into
the behavior of these interrelated groups of activities. Measures are gathered from tasks
and activities which form complex, goal-oriented processes. Activity level measures are
rolled up to department and division levels until consolidated measures finally summarize
operations for the health department as a whole.

A system is an organized collection of parts, functions, or subsystems that are integrated

to accomplish an overall goal. The system has various inputs which are acted upon by
certain processes to produce outputs, which together accomplish the overall desired goal
for the system. A system is usually made up of smaller systems or subsystems. For
example, an organization is made up of many administrative and management functions,
products, services, groups, and individuals. If one part of the system is changed, the
nature of the overall system is often changed. 1

The goal of any organization is to build a highly functioning system that continually
exchanges measurement feedback among its various parts. This constant exchange of
measures ensures that activities remain closely aligned and focused on achieving the
goals of the organization. If any of the parts or activities in the system seems misaligned
through its measurement monitoring program, the system must make necessary
adjustments to achieve its goals more efficiently. 2

Work Processes Integrate to Form a System

Both a systems view and a functional view of work processes are important to understand
how the subsystems, or functions, are interrelated. The interrelationship usually is in the
form of inputs and outputs which are delivered to internal or external customers. These
inputs and outputs can be measured both quantitatively and qualitatively to determine
how the parts and the system are functioning and where improvements should be made.
Figure 4.1 shows a system and functional view of work processes. Big “Q,” at the left of
Figure 4.1, relates to the quality functions required to sustain the overall performance of

1
McNamara C. Free Management Library. http://managementhelp.org/systems/systems.htm. Accessed
February 5, 2011.
2
McNamara C. Free Management Library. http://managementhelp.org/systems/systems.htm, Accessed
February 5,2011.

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Modular kaizen: Dealing with Disruptions Chapter 4
the organization as it relates to its environment of suppliers and customers. The system
level functions of quality are decompressed into smaller functions related to individual
programs or departments at the tactical and operating levels of the organization. Little “q”
improvements, at the right of the figure, are tasks that create change.

Functional
View
Departments
Programs or

Departments

Departments

Departments
Programs or

Programs or

Programs or
Systems View Little “q”
Improvements
Big “Q”
Cross Functional
Improvement

Figure 4.1: Big “Q” drives to little “q”

Quality improvement (QI) in public health is a never-ending process that pervades the
organization when fully implemented. Top organizational leaders address the quality of
the system at a macro level (Big “Q”). In the middle, professional staff attack problems
in programs or service areas by improving particular processes (little “q”). At the
individual level, staff seek ways of improving their own behaviors and environments
(individual “q”). 3 Figure 4.2 is a comparison of the strategic, tactical, and operational
levels of Big “Q,” little “q,” and individual “q” within an organization. Modular kaizen
uses the focusing effect of measurement to translate the performance management
strategies identified by leadership (Big “Q”) down to the functional or departmental
activities (little “q”).

3
Duffy G, Moran J, Riley W. Quality Function Deployment and Lean-Six Sigma Applications in Public
Health. Milwaukee, WI: Quality Press; 2010.
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Modular kaizen: Dealing with Disruptions Chapter 4
 Topic Big ‘Q’ – organization-wide Little ‘q’ – program/unit Individual ‘q’

Improvement Specific project focus System focus Daily work level focus

Quality Improvement Program/unit level Tied to the strategic plan Tied to yearly
Planning individual performance

Evaluation of Quality Performance of a Responsiveness to a Performance of daily

process over time community need work

Processes Delivery of a service Cut across all programs Daily work

and activities

Quality Improvement Individual program/unit Strategic Plan Individual performance

Goals level plans plans

Figure 4.2: Contrasting Big “Q,” Little “q,” and Individual “q”

When starting their quality journey, public health organizations tend to embrace little “q,”
which means striving for quality in a limited or specific improvement project or area.
This endeavor is accomplished by utilizing an integrated set of QI methods and
techniques that help to create a value map, 4 identify the key quality characteristics,
analyze process performance, reengineer the process if needed, and provide methods to
lock in improvements. Little “q” can be viewed as a tactical approach to implementing
quality and beginning to generate a culture of QI within the organization. 5

Involve People in Describing Processes

The overall concept of managing a complete system of organizational processes includes

designing, executing, and optimizing cross-functional business activities that incorporate
people, technology, processes, and often community partners. Health departments are
expert at involving the community in utilizing scarce resources in innovative ways to
resolve problems. Many successful improvement teams involve a combination of staff,
community partners, subject matter experts, and specialized consultants who share their
expertise for the most efficient resolution to a problem.

4
A value map is a specialized process map which identifies monetary or other quantitative measures of
where value is added by the activities performed within a process.
5
Beitsch L, Bialek R, Cofsky A, Corso L, Moran J, Riley W. Defining Quality Improvement in Public
Health. Journal of Public Health Management and Practice, 2009; 16(1): 5-7.

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Modular kaizen: Dealing with Disruptions Chapter 4
 Process - Level #1

Step #1 Step #2 Step #3

Process - Level #2

Step #1 Step #2 Step #3

Process - Level #3

Step #1 Step #2 Step #3

Select
Selectthe
theappropriate
appropriateprocess
processlevel.
level.

Figure 4.3: Example of the hierarchy of processes from organizational to individual

task level

Figure 4.3 illustrates the categorization of a high-level process into steps which can be
further categorized into processes at a more detailed level. As the process is expanded
from a strategic design to actual work instructions, the level of detail within each process
becomes greater until finally the process is equivalent to a work instruction for an
individual performing the work. Chapter 10, Daily Work Management, describes this task
level and the importance of the individual in identifying disruptions and other
opportunities for improving efficiencies within the organization.

Analyze System Disruption

When a disruption occurs in a stable system, the impact it has caused must be defined.
One way to analyze the disruption is to identify what has been impacted in the overall
system using a Disruption and Impact Matrix as shown in Figure 4.4. The first thing to
understand is what areas were impacted in the current stable state. These impacted areas
are called Areas of Concern (AoC). AoCs can be functional as well as system-level
concerns. Once the AoCs are documented, a broad sense of how they are impacted is
determined. The next step is to analyze whether the impacted areas are under the control
or influence of the organization. If the organization controls the process under study,
action can be taken directly to minimize the impact. If the organization can only
34
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Modular kaizen: Dealing with Disruptions Chapter 4
influence the AoC, taking action might be slower since others may need to be involved
before making decisions to stabilize the current state. Once we begin to analyze the AoC
over which we have control, the Force and Effect Diagram + ca, described in Chapter 6,
is a very useful tool to help a response team begin to check and then take small action
steps to stabilize the situation.

How? Areas of Concern

Disrupted State
AoC
Control
AoC

Impacts Disruption

Influence AoC

AoC

Current Stable State

Figure 4.4: Disruption and Impact Matrix

The AoCs should be prioritized within both control and influence categories. It is best to
start with the AoCs that have been most strongly impacted since these are usually the
ones upon which to focus limited resources.

Modular kaizen, as an approach based on the lean family of improvement tools, views the
interaction among processes within the organization from an efficiency perspective.
Figure 4.5 illustrates methods by which lean activities seek to reduce waste and eliminate
redundancies as work is performed. A typical process is shown in Figure 4.5 on the left
with embedded error correction, unnecessary tasks, and queuing or waiting before
outcomes are realized. The more efficient process flow on the right shows a very direct
flow to the desired outcome.

35
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Modular kaizen: Dealing with Disruptions Chapter 4
 ...and a lean value stream for the
same process:

A typical waste-filled value stream... Desired

Outcome
Unnecessary
Task Desired
Outcome
Task Waits
Error-Correction in Queue
Loop
Approval
Cycle
Deliverable
Created
Figure 4.5: Comparison of typical process waste and the efficiency of a lean process

Modular kaizen uses the existing pace of the organization to plan improvement activities
based upon the highest priority areas of impact. Figure 4.6 illustrates the concept of
Kaizen activity as a series of improvement steps interspersed with standard operations.
When a problem is encountered, a Kaizen activity is planned and implemented, thus
raising the standard of performance for the impacted process. As actual performance is
improved, the standard is raised.

Perpetual System of Improvement

Standard
Performance

Standard (Capability)
Kaizen
Actual (Performance)
Kaizen Problem
Standard Problem

Time
Standard Record of best known method to perform work repeatedly

Problem Actual performance has fallen below proven capability

Kaizen Develop a better method to perform work repeatedly

Figure 4.6: The Kaizen method of perpetual improvement

36
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Modular kaizen: Dealing with Disruptions Chapter 4
Figure 4.6 is a generic illustration of continuous lean Kaizen process improvement.
Traditional Kaizen approaches are designed to group improvements into short, intense
bursts of activity which remove the response team from normal operations. An even more
focused approach is the Kaizen Blitz, which sequesters the response team until the
improvement is defined, piloted, and initially implemented. Although the Kaizen Blitz is
an effective approach for high severity situations where work cannot continue until the
problem is resolved, not all improvement situations require such drastic means. The
benefit of Modular kaizen is that improvements are integrated into daily work activities,
based upon the impact of the disruption, resources, and personnel available. Detailed
examples of integrated improvement are shared in subsequent chapters.

Once the focus of analysis efforts is understood, the next step is to define the disrupted
process at a high level. The tool for either a system or functional view of a process is a
SIPOC + CM Form shown in Figure 4.7 and a completed SIPOC + CM in Figure 4.8.

S I P O C + CM Form
Constraints: Ends With:
Begins With:

Process/Activities:

Measures

Outputs:
Inputs:

Suppliers: Customers:

Figure 4.7: SIPOC + CM Form

The SIPOC + CM Form is a data collection form employed to illustrate a system or

functional view of a process. It helps the response team gather relevant information about
the process, including suppliers, inputs, the high-level process steps, outputs, and
customers. The SIPOC + CM Form also prompts the user to identify key measures that
assure alignment with organizational priorities, along with constraints that impact the
process in its current state. The SIPOC + CM Form is a high-level view of the “As Is”
state of a process under investigation.

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Modular kaizen: Dealing with Disruptions Chapter 4
6

Figure 4.8: Completed SIPOC + CM

Form6

6
SIPOC + CM form completed by the Iowa Department of Public Health, Bureau of Family Health for
Title V Maternal Health Program. Contributed by Ms. Janet Beaman, Iowa Department of Public Health,
2011.
38
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Modular kaizen: Dealing with Disruptions Chapter 4
A SIPOC + CM Form is useful to capture the basics of the process under study. Using the
SIPOC + CM Form is a vehicle to get the collective knowledge of team members about a
process recorded in an easily viewable format or when concise communication about the
process must be conveyed to others.

The process to develop a SIPOC + CM is:

 On a piece of flip chart paper, draw the SIPOC + CM diagram with seven blocks
indicating the components of SIPOC.
 Clearly identify the process under study and define the process boundaries (start
and end points) so that all participants understand the scope of the analysis.

On the SIPOC+CM form, identify the data available for each of the following major
categories:
 Suppliers – who or what (internal or external) provides the raw materials,
information, or technology to the process
 Inputs – what material or information specifications are needed by the process
 Process – a high-level Flow Chart of the key five to seven core activities that
comprise the process, offering a 35,000 foot view of the process. The detail steps
will be developed in a flowchart.
 Outputs – what the process produces as products, services, or technology
 Customers – the main users of the process’s output
 + C – constraints facing the system or process
 + M – measures being used or to be used to manage the performance of the
process

Review the form for accuracy with relevant stakeholders, sponsors, and other interested
parties.

The SIPOC + CM is the initial picture of a process. Once the general expectations of the
process are agreed upon, the next step is to define the process at the level of individual
steps and tasks. Depending on the purpose of the map, one of three major categories of
maps may be used.

Process Maps Provide Different Views of the System

Figure 4.9 provides an overview of the three major types of process mapping tools: value
map, process map, and flowchart.

A value map is a high-level representation of the process which guides the team through
identification of where activities increase the value of the process output in the eyes of
the customer or final user. This tool, often called a value stream map, is a system-level
instrument, since value is often added through a series of interrelated processes. The
result of changing one process in the stream of activities may negatively impact the
39
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Modular kaizen: Dealing with Disruptions Chapter 4
efficiency of another process within the system. The intent of the value map is to remove
all activities which add no value to the end product or service and to reduce any waste
which makes those process steps that add value less efficient.

Value Map, Process Map & Flowchart

Value Map Process Map Flow Chart

(Value Stream Map)
Starts with first process block Starts with inputs Starts with start block

Focuses on one service from Identifies individual Identifies each step of a

beginning to end process of a larger process
process
Does not use decision boxes Has very few Has many decision
decision boxes boxes
Ends with last process block Ends with outputs Ends with end block
Encompasses the complete set of May be part of a Is usually a procedure
processes and/or steps procedure on its own
representing a defined value
stream
Illustrates value versus non-value Helps paint a high Helps paint a detail
added process activities level picture picture

Figure 4.9: Value Map, Process Map, & Flowchart characteristics compared

The process map is a symbolic representation of a single process without a lot of detail.
The intent is to provide a high-level picture of the steps within a process. This picture
provides a strategic view of how one process may impact others and assists in the overall
balancing of resources across a set of interrelated processes.

A flowchart is a detailed picture of a process at the procedural level. This version of a

process map includes steps, decisions, inputs from outside the process, and outputs or
interchanges with resources or other activities outside the process. The flowchart
provides enough information about the process to establish working measures for
monitoring and improving outcomes or interim milestones.

40
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Modular kaizen: Dealing with Disruptions Chapter 4
 Processing
Verify
Application WIII
Verify with Data

C/T 9 days (D7

Avg. 5/07)

W/T

Figure 4.10: As-Is Value (Stream) Map of Florida agency customer intake process –
2008 7

The example in Figure 4.10 illustrates the output of a value stream map. Each step of the
series of processes is measured for wait times, number of persons waiting, cycle time for
each step, and total elapsed time. Also included is use of resources (procedures,
materials, personnel, etc.). This example does not convert time values into dollar
amounts, although many value maps do. The intent of using this version of process map
is to reduce disruption and time through the total flow of the overall system comprised of
interrelated processes.

Figure 4.11 is a basic process map of a health department childhood immunization clinic.
This high-level picture of clinic flow provides enough information for communication
about the general operation of the activity. Little detailed information is available from
this map type. The intent here is to focus the scope of discussion around a particular
activity.

7
SIPOC + CM form completed by the Florida Department of Public Health.
41
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Modular kaizen: Dealing with Disruptions Chapter 4
 Yes
Need Give Child leaves clinic
Child arrives at clinic Register
Immunization Immunization

No

Figure 4.11: Basic Process Map for Childhood Immunization Clinic

The detailed flowchart reflected in Figure 4.12 shows enough detail to identify activity
and some outcome measures. The level of each block or decision symbol in the example
Septic Systems Permitting flowchart is at the point where a work instruction or procedure
could be the next level of granularity if more detail were desired.

Original Septic system permitting

flowchart

rehost

Figure 4.12: As-Is Flowchart of Environmental Services Department Septic System

Permitting
42
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Modular kaizen: Dealing with Disruptions Chapter 4
Understand the System to Manage Performance

Understanding individual processes is critical for measuring and maintaining

organizational performance. Improving processes individually, however, without
assessing the interconnected impact of change to related processes is a recipe for
inefficiency. The tools introduced in this chapter provide the reader with the ability to
envision the interrelated nature of the department as a system of processes to meet the
strategic goals of the organization. Change management and the ramifications of
performance management on the overall operation of the health department are covered
in subsequent chapters. Once the overall expectations of system performance are
understood, additional tools are available to define the cause of disruptions and analyze
the best alternatives for reducing or eliminating waste and defects. Change and
improvement are successful when accomplished at the level of daily work management.
These accomplishments are integrated into the overall activities of the organization.
Performance management techniques capture the results of these improvements at the
middle and senior management levels.

The concept of Modular kaizen is dependent upon accurate measures to move effectively
through the planned steps of an improvement project. Organizing tasks within a Modular
kaizen project includes a possibility that one task may be performed and the next task left
to wait until the improvement team comes together again much later to pick up the
problem-solving and decision-making. Having a well-defined, organized matrix of
requirements provides a solid foundation for resuming effective operations after a
planned hiatus.

Modular kaizen suggests the development of a Tri-Metric Matrix to support performance

management for most processes. The Tri-Metric Matrix helps guide the decision maker to
measure the important aspects of a process’s capacity, process capability, and outcomes.
Because of the interrelated nature of processes within a total system, the overall capacity,
capability, and outcome of one process is usually dependent upon interaction with other
processes. Chapter 7 describes the Tri-Metric Matrix and how it supports the overall
performance of the organization using the Modular kaizen approach.

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Modular kaizen: Dealing with Disruptions Chapter 4
 44
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Modular kaizen: Dealing with Disruptions
 Chapter 5: Focus on the Disruption – Develop the Response Team

Introduction

The main enemy of efficient operations is disruption. Anything that hinders the smooth
and efficient flow of interactions between organizational processes required to reach the
goal must be identified and removed. Chapter 1, The Value of Performance Management,
introduces the importance of tying improvement efforts to the key performance indicators
of the organization. Chapter 4, System View of the Process, explores the intricate balance
of minimizing disruption among cross-functional processes and the broader challenge of
efficiency across suppliers, organizations, and customers.

Disruption Identification

Modular kaizen Flow

Plan

Do/
Act Disrupt
Di
sru
Check pti
on
check

Modular act
do
Kaizen

plan

Figure 5.1: Using the “Check:” phase to Identify Disruption

The iterative check and act cycle described in previous chapters is the basic building
block for minimizing disruption. The Plan-Do-Check-Act (PDCA) cycle shown in Figure
5.1 is constantly comparing what is actually happening in a process to what is supposed
to happen. Figure 5.2 illustrates a simple gap analysis model where a sensor is applied to
a defined process (1). The sensor (2), either technical or human, compares the measured
process performance against an expected goal (3). Depending on the comparison of
actual performance to the goal, an actuator is employed. If the comparison is equal to
actual or within specified performance limits, the actuator (4) may simply document that
performance is within expected variation and return to normal processing (5). If the

45
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Modular kaizen: Dealing with Disruptions Chapter 5
comparison shows actual performance beyond normal variation, the actuator performs
additional measures to ascertain whether the process is capable of meeting expected
outcomes through improvement or redesign, if necessary.

Figure 5.1 makes allowances for the three different actuator responses, based upon the
severity of the disruption. The check phase in the routine PDCA cycle monitors key
performance indicators for sustainability of normal operations. When either technical
equipment or front-line personnel observe a disruption that is beyond normal process
variation, the Modular kaizen flow enters the Check–Act–Plan–Do (CAPD) Modular
kaizen response cycle.

The Check phase in the CAPD Modular kaizen cycle gathers additional data to assess the
severity of the disruption identified by the Do phase in the routine PDCA cycle. If the
disruption can be resolved with minimal improvement to the process or related resources,
the Act phase is employed to return the process to normal operation. The green and red
arrows in Figure 5.1 show entry into the CAPD cycle from the routine PDCA cycle, entry
into the Act phase to resolve the minimal disruption, and return to the PDCA cycle of
normal operations.

If the Check phase in the CAPD Modular kaizen response cycle indicates that the
disruption is severe enough to require significant improvement or redesign of the process,
the whole CAPD cycle will be activated. The response team will analyze the data from
the Check phase, use the Act phase to identify alternative solutions to the disruption,
move to the Plan phase to design the specific improvement or total redesign, then pilot
the solution during the Do phase of the CAPD cycle. If the pilot solution resolves the root
cause of the disruption, the operation returns to the PDCA cycle to formalize the changes
and update documentation for sustainability. If the solution does not meet long-term
requirements, the response team remains in the CAPD Modular kaizen cycle for
continued measurements and improvement efforts.

Prioritize Disruptions Based Upon Areas of Concern

Modular kaizen uses the key performance indicators (KPIs) established during strategic
planning to prioritize work on minimizing disruption. KPIs are established as the basis
for performance management across the total set of processes which comprise the
organization. Performance management tracks KPIs on a consistent basis as the target
for identifying disruptions. Modular kaizen analyzes the disruption during the Check
phase as Areas of Concern for further data gathering and response team action.

Figure 5.2 illustrates the sequence of activities to establish measures and indicators at the
daily work management level. As indicated in Chapter 1, The Value of Performance
Management, the head of an organization and functional directors set organization-level

46
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Modular kaizen: Dealing with Disruptions Chapter 5
goals and objectives, based upon the Voice of the Customer. 1 A working draft of the
strategic plan, including high-level objectives and outcomes, cascades down through the
organization to be assessed by those who will perform the daily work to accomplish
the tasks.

Alignment “Vertically” Within the Organization

Duffy 2005

Figure 5.2: Align core processes vertically within the organization

As shown in Figure 5.2, policy is deployed to the workforce, while actions, dates, and
tasks to meet goals and objectives are returned upwards for validation and integration
into a final strategic plan. Measures and indicators can only be efficiently created once
tasks are identified. High-level outcome indicators and generic performance expectations
are set for all objectives in the early stages of strategic planning. Once the policies, goals,
and objectives cascade downward into the organization, management, team leaders, and
workforce verify capability of operations level processes to meet the high-level indicators

Once an Area of Concern (AoC) is identified by the response team, a Disruption and
Impact Matrix is used to clarify the details of the situation. Figure 5.3 shows a Disruption
and Impact Matrix with a number of AoCs listed in table format. The matrix is developed

1
Voice of the Customer (VOC) is a result of an organization’s efforts to understand customers’ needs and
expectations and to provide products and services that truly meet such needs and expectations.
47
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Modular kaizen: Dealing with Disruptions Chapter 5
along a force field analysis 2 concept which seeks to minimize the disruption by
strengthening the ability of the AoCs to meet customer requirements or performance
management objectives. The end goal of the Disruption and Impact Matrix is to guide the
response team to return the disrupted state to the current, desired state of the process.

How? Areas of Concern (AoC)

Disrupted State
AoC
Control
AoC

Impacts Disruption

Influence AoC

AoC

Current Stable State

Figure 5.3: Disruption and Impact Matrix

An additional aspect of the Disruption and Impact Matrix is the left column - Control and
Influence. This column prompts the response team to ascertain whether they are in
control of the AoC and its resolution or whether they can only influence the resolution of
the disrupted state. Different behaviors are required when attempting to influence the
outcome of others’ actions, rather than being in control of the resources and decisions.
Figure 5.4 is a representation of a Circle of Influence.

Figure 5.4: Circle of Influence

2
For more information on Force Field Analysis, refer to Bialek R, Duffy G, and Moran J, The Public
Health Quality Improvement Handbook. Milwaukee, WI: Quality Press; 2009.
48
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Modular kaizen: Dealing with Disruptions Chapter 5
The authors have found a useful approach for involving others in the resolution of
process disruptions from Dr. Stephen R. Covey. 3 The most effective area in which to act
is that in which we have the strongest control. As seen in Figure 5.5, the area of control is
in the center of the Circle of Influence. Process owners and those who control the
resources that support public health programs have the best opportunity to assess and
anticipate areas of disruption to those programs. They call the shots; they own the
environment.

The next most effective area in which to manage disruption is where strong partnerships
with customers, community, corporate sponsors, and related agencies exist. This area is
one in which some level of influence over the use of resources and the eventual outcomes
of the programs of involvement are evident. A group may not own the resources, but it
can use its relationship with others to guide the positive outcomes of activities and
decision-making.

The outer loop of concern is the highest level of risk for both positive and negative
consequences of decisions or actions. Areas where a person is interested in the outcomes
but has little or no ability to guide and influence the actions of others require a complex
set of relationships. Response teams are often on the edges of the activity and outcomes
for programs such as this. It is important not to commit scarce resources, personnel, or
reputation on the outcomes of programs where potential exists but influence or control
over what happens is not available.

The control and influence column in Figure 5.3 leads the response team to the initial
consideration of how to address the AoC to impact the disruption most efficiently. The
“How” column in Figure 5.4 can only be addressed once the team understands how much
control they have over the resources required to affect changes to the disrupted process.
Chapter 6, Modular Flow/Rapid Cycle, will introduce additional tools to drill down into
the details of the disruption to gather specific data and implement effective and efficient
resolutions based upon the performance management requirements of the organization.

Choose a Team that Tolerates Conflict

The response team chartered to address the disruption and return the impacted process to
standard operation will need a strong set of skills and behaviors which include conflict
management. Conflict is a recognized stage in the team development process. Scholtes,
Joiner, and Streibel describe the four phases of team development (forming, storming,
norming, and performing) in The Team Handbook. 4 Since conflict will happen during
most disruption response activities, it might as well be beneficial.

3
Covey S. The 7 Habits of Highly Effective People. New York: Simon & Schuster; 1990.
4
Joiner B, Scholtes P, Streibel,B. The Team Handbook, 2nd ed. Madison, WI: Oriel Incorporated; 2000.
49
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Modular kaizen: Dealing with Disruptions Chapter 5
Conflict between or among team members can occur at any of the stages but is more
likely to surface during the Forming and Storming stages. Conflict is common and useful.
It is a sign of change and movement. Conflict is neither good nor bad. The effort should
not be to eliminate conflict but to refocus it as a productive rather than destructive force.
Conflict can be a vital, energizing force at work in any team. When conflict occurs within
or among teams, it should not be ignored. Addressing the conflict, using it to find the
friction that change has created within the team, and using problem-solving techniques to
resolve and improve the situation generate more positive outcomes.

When addressing a disruption in core business processes, it is common to experience

conflict among interested parties. The response team can use this conflict to initiate
positive change in resolving the disruption. Tools such as Force Field Analysis, and
Force & Effect + ca 5 , and effective facilitation techniques, are useful in drawing conflict
into the open for direct communication among the conflicted stakeholders. The goal is to
use the issues in conflict to select the most efficient resolution that is consistent with
organizational or customer requirements.

Leaders, with guidance from a facilitator if needed, can help to transform a conflict into a
problem-solving event by:
 Welcoming differences among teams, team members, and stakeholders
 Listening attentively with understanding rather than judgment
 Helping to clarify common goals among the conflicting parties
 Acknowledging and accepting the feelings of the individuals involved
 Offering support to the parties in resolving the differences
 Reinforcing the value of each of the parties to the organization as a whole
 Creating appropriate means for communication between those involved in the
conflict

No matter what form teams take, common characteristics of all successful teams exist.
The organization must focus on integrating these characteristics into daily work
management BEFORE implementing the team concept. Much is written about these
components of effective team building; this chapter covers the basics.

John Zenger 6 includes the following as some crucial characteristics for members when
first initiating a team environment:
 Common goals;
 Leadership;

5
The Force & Effect + ca tool is described in Chapter 6, Modular Flow/Rapid Cycle.
6
Zenger, et al, Leading Teams, Mastering the New Role. San Jose, CA: Zenger-Miller, Inc; 1994.
50
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Modular kaizen: Dealing with Disruptions Chapter 5
  Involvement;
 Self-esteem;
 Open communication;
 Power to make decisions;
 Planning;
 Trust;
 Respect for others; and
 Conflict resolution.

These characteristics are major contributors to high employee morale. They also
positively influence customer satisfaction, whether internal or external. The same skills
that leaders are required to use work well at all levels of the organization. Figure 5.5
summarizes many of the characteristics and elements of dynamic and successful teams.

Figure 5.5: Characteristics of an Effective Team 7

7
Beecroft GD, Duffy G, Moran J. The Executive Guide to Improvement and Change. Milwaukee, WI:
Quality Press; 2002.
51
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Modular kaizen: Dealing with Disruptions Chapter 5
Application of Disruption and Impact Matrix

The quality improvement (QI) team for a local health department was called upon to
address a severe disruption in the immunization department. Records in the immunization
database were incorrect or missing, causing insufficient vaccine re-stocking, lost funds
recovery, and incorrect patient records. Figure 5.7 is the Disruption and Impact Matrix,
reflecting the response team’s first assessment of the Areas of Concern for improvement
or redesign. The disrupted state is identified on the right side of the form as “Records
incomplete or missing. Vaccines unaccounted for.” The current stable state was entered at
the bottom of the form as “All immunization records correctly updated by End of Day.
All vaccines accounted for and expiration dates controlled.”

The team observed the clinic immunization process and discovered that the nursing staff
was not updating the customer record at the end of each immunization event. Some
nurses had not been trained on the immunization data collection application so were
either guessing what fields to fill in or asking another nurse to perform the update for
them. The backlog of updates often rolled into the next day, when memories were less
accurate, thereby further corrupting the information.

How? Areas of Concern (AoC)

Disrupted State
AoC
Control
AoC

Impacts Disruption

Influence AoC

AoC

Current Stable State

Figure 5.6: Disruption and Impact Matrix for Immunization Response Team

The team agreed that the local health department staff controlled when the record was
updated and what data was entered into the collection screen. The top two Areas of
Concern in Figure 5.6 are in the “Control” area of the form. The team also realized that
the shipment of replacement vaccine was not under health department control but could
be heavily influenced by having correct inventory information in the database from which
the supplier drew restocking counts. Likewise, funding came from outside the department
52
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Modular kaizen: Dealing with Disruptions Chapter 5
and was also based upon the quantity of vaccine used and the population served. Supply
and Funding Areas of Concern were placed in the “Influence” area of the form.

The response team used the visual representation provided by the Disruption and Impact
Matrix to brainstorm efficient solutions to the process disruptions. Their goal was to
strengthen the impact of the Areas of Concern - Accurate, Timely, Supply, and Funding -
in order to minimize or eliminate the disruption. The team came to consensus on “How”
each impact would be addressed and added this information to the form. The “How” at
this point was a high-level suggestion requiring implementation planning. This scenario
will be continued in Chapter 6, Modular Flow/Rapid Cycle, with further drill down into
disruption resolution.

53
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Modular kaizen: Dealing with Disruptions Chapter 5
 54
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Modular kaizen: Dealing with Disruptions
 Chapter 6: Modular Flow for Rapid Cycle Improvement

Modular kaizen is a structured plan for scheduling improvement tasks, including the
availability of information and resources in units which can be performed within the time
limits of a busy and interruption-filled work environment. This planning involves
employees in a well-defined context of tasks and deliverables closely aligned to the
highest priorities of the department. Modular kaizen takes advantage of the lean concept
of Rapid Cycle Plan-Do-Check-Act (PDCA) to plan and implement improvements
quickly and effectively, using the resources available in the time allowed.

Although Modular kaizen is also effective with more complex improvement models such
as Define-Measure-Analyze-Improve-Control (DMAIC) or Design for Six Sigma
(DFSS), this text focuses on the entry level model of PDCA. Later publications will
associate the Modular kaizen approach to more complex improvement models.

While it is tempting to think that a single improvement approach will work well for an
entire organization, the workplace is rarely so tidy. In reality, the unit of improvement
activity should be matched to the response team members’ specific jobs and roles—or at
least distinct categories of jobs and roles. To resolve a disruption in an individual
department or function, it is not enough to launch a set of organization-wide initiatives or
to count on a piece of application software. Instead, leaders of busy health workers must
understand the specific task needs of their personnel and tailor improvement activities to
these requirements.

Few organizations have thought systematically about where additional structured

improvement planning could enhance efficiency. A good starting point is to identify the
working characteristics of response team members and understand the range of tasks that
they perform. The unit of analysis should be a particular job, not the organization as a
whole. This practice is important in Modular kaizen because different professionals and
staff within the same organization often have very different knowledge and information
requirements. Furthermore, information is more readily structured for some jobs than for
others, and some workers might resist planned improvement activities more than others.
Change management techniques to assist in matching approaches to working styles are
addressed in a later chapter.

Too often we encounter teams or organizations that launch an improvement effort but
take three months to do what could be accomplished in three days or three hours. They
waste too much time and energy by not solving the problem quickly. These teams fail to
hold the gains or move on to the next organizational challenge. Consequences of
improperly planning an improvement initiative or not engaging in Rapid Cycle PDCA is
that team members lose interest, become bored with a long process, do not gain
experience and knowledge in applying QI, and do not see the impact of their efforts for a
long time.
55
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Modular kaizen: Dealing with Disruptions Chapter 6
So what is Rapid Cycle PDCA? The word “Rapid” means completed or occurring in a
brief period of time and characterized by speed. “Cycle” means an interval during which
a recurring sequence of events occurs. 1 Therefore Rapid Cycle PDCA, as shown in
Figure 6.1, is applying the recurring sequence of PDCA in a brief period of time to solve
a problem or issue facing a team or organization that will achieve breakthrough or
continuous improvement results quickly. 2

PDCA should be repeatedly implemented in spirals of increasing

knowledge of the system that converge on the ultimate goal, each
cycle closer than the previous.

A P

A P C D

Project Difficulty
A P C D
Rapid
C D Cycle*
Hold the Gains

Knowledge & Experience

Figure 6.1: Rapid Cycle PDCA as a sequence of increasingly difficult improvement

acts

Modular kaizen uses the concept of Rapid Cycle PDCA to plan improvements in task
level activities that can be performed quickly. These focused tasks are interspersed with
daily work normally performed by response team members. Daily work management is
explained in Chapter 10.

Figure 6.2 shows the Rapid Cycle Process Model which defines the steps to ensure a
successful rapid cycle application of PDCA.

1
The Trustees of Princeton University. Wordnet: A lexical database for English.
www.wordnet.princeton.edu. Published 2011. Accessed February 14, 2011.
2
Duffy G, Moran J, Riley, W. Rapid Cycle PDCA. Quality Texas Foundation Update. August, 2009.
56
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Modular kaizen: Dealing with Disruptions Chapter 6
 Understand the
issue, and Current State
Consultative
Define the desired Future Training &
State Team
Formation
Develop a clear
AIM Statement

Rapid Cycle Period

Complete Rapid Cycle PDC/SA Checklist
Repeat the Define the Improvement Timeline
Rapid PDCA Apply Training
Cycle Analyze Baseline Data
Develop Solutions
Monitor and Hold Launch Pilot Improvements
The Gains Additional training sessions
Develop improvement measures
Evaluate results
Figure 6.2: Rapid Cycle PDCA/PDSA Process Model 3

The Rapid Cycle Process is defined as follows:

 Realization of a problem to correct. Management is committed to making the

change.
 Act to start a resolution or change to the problem by utilizing the QI tools and
techniques.
 Plan for success by developing a clear AIM statement.
 Involve key constituents in the PDCA process.
 Develop the change team and establish the rapid cycle timeline.

 Consultative training interventions as required by the team occur.

 analYze baseline data and understand the current state and scope of the problem.
 Construct solutions to get to the desired future state.
 Launch pilot improvement solutions to determine if the desired change can be
achieved.
 Evaluate results achieved from pilot improvement, make any necessary
adjustments, and launch it throughout the organization.

3
Duffy G, Moran J, Riley, W. Rapid Cycle PDCA. Quality Texas Foundation Update. August, 2009.
57
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Modular kaizen: Dealing with Disruptions Chapter 6
The utilization of a Rapid Cycle PDCA process helps organizations realize a quick return
on their investment in QI. Some of the benefits of instituting Rapid Cycle PDCA are:
 Short cycles of change to accelerate quality improvement (QI) in the organization;
 Hold the gains as a platform for the next level of project improvement;
 Development of a broad base of QI knowledge and experience in the organization
that will help in the establishment of an organization-wide culture of quality and
excellence;
 Solutions to many organizational problems that will promote needed
organizational change and improvement; and
 Provision of an iterative opportunity for team members to reinforce their QI
knowledge quickly in the next project.

A Pre-Planning Check Sheet has been developed to help in using Rapid Cycle PDCA 4
(see Appendix C). The Check Sheet contains questions that guide the response team
when starting a Rapid Cycle or Modular kaizen QI project. This checklist addresses the
Rapid Cycle pre-planning to ensure a successful improvement project. The Check Sheet
provides columns to indicate what has been completed (√) and what needs to be done
(TBD) along with the expected completion date.

Example of Modular kaizen flow of tools and techniques

The Modular kaizen approach to rapid cycle improvement is structured to fit within the
existing time and resource requirements of the response team, resolving the disruption.
The rest of this chapter illustrates the flow of planning and design of a Modular kaizen
event related to the major power outage scenario introduced in Chapter 3. A number of
the elements of the House of Modular kaizen are employed to identify the disruption,
focus on high priority Areas of Concern, map a process to respond to the disruption in the
short term, and implement a full PDCA cycle to resolve the disruptive issues through
strategic process improvement and redesign.

Not all elements of the House of Modular kaizen found in Chapter 2 (Figure 2.2) are
required for each disruptive occurrence. The elements illustrated in the Major Urban
Hospital Power Outage example are:
#4: Disruption Identification #12 Quality at Source
#6: Force and Effect + ca #13 Process Control
#7: Tri-metric Matrix #14 Fast Transition
#8: Teams #17 Daily Work Management
#9: Project Management

4
Some Rapid Cycle explanations refer to the Plan-Do-Study-Act (PDSA) cycle rather than PDCA. Dr.
Deming used the PDSA term in later years to reduce the tension sometimes generated by using the word
“check.” The “check” term is used with Modular kaizen to refer to continuous monitoring and measuring
in support of organizational performance management.
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Modular kaizen: Dealing with Disruptions Chapter 6
The continuous monitoring of operational performance is the entry point for disruption
identification. Frequently, standard measures of key department objectives will provide
data indicating that something is hindering the smooth flow of a critical process. These
subtle indicators are often missed in a highly interruption-filled organization because
people are focused on immediate tasks. A combination of project management, tri-metric
matrix (Chapter 7), and daily work management (Chapter 10) provides the opportunity
for team leaders, senior management, or front-line staff to compare actual process
performance against the documented standards of performance.

Figure 6.3 is the completed Association of Disruption to Area of Concern (ADAoC)

Form for the power outage scenario. The form provides a checklist of major causes of
disruption within organizations. Other sources of disruption can be added to the form to
personalize the instrument. In this scenario, the disruption was quite apparent as soon as
it happened. No power in a busy, urban hospital is a catastrophe with multiple associated
disruptions.

The four major disruptions identified for the power outage were:
 Balancing work priorities
 Competing assignments
 Environmental conditions
 Unavailability of equipment, tools, or documentation
Senior management rallied immediately, as seen in the scenario introduced in Chapter 3,
by calling a situation meeting at 6:30 AM to check the current status of hospital
operations and patient schedules. Teams were assigned to check the status of patients,
surgery schedules, power generators, room temperatures, rehabilitation center
appointments, and other Areas of Concern stemming from the total loss of power within
the facility. Figure 6.4 is a Disruption and Impact Matrix listing the major Areas of
Concern (AoC) facing senior hospital leadership. The AoCs are categorized as those
within the control of the hospital or only able to be influenced by senior leadership. The
“How” to address the area depended on the level of control the hospital had on the AoC.
For example, rescheduling elective surgery was completely within the control of
operating room administration. Without power in the facility, lowering the temperature
on a hot July day needed assistance from outside the hospital and could only be
influenced by senior leadership.

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Modular kaizen: Dealing with Disruptions Chapter 6
Association of Disruption to Area of Concern: Long-Term Power Outage in Large,
Urban Hospital
√ Potential Cause of Disruption How the Disruption Impacts Specific Daily Work
Management
√ Balancing Work Priorities – The immediate need to anticipate and prepare for a
fluctuating work demands that create potentially long power outage in the hospital
an unstable work schedule observed destabilized existing morning rounds, scheduled
to interfere with performance based surgeries, and other daily management activities.
upon key performance indicators Although the high-priority requirement to prepare
for the power outage was critical, a need to
maintain a minimum service level for some patients
and transfer others who could not be
accommodated in-house was unavoidable.
Implementation failure– failing to
translate a customer requirement
into concrete action within the
performance parameters
√ Competing Assignments – Facilities, security, maintenance, nursing,
interference from other tasks that are physicians and administrative staff were required to
customarily performed parallel to perform normal daily management activities while
this process taking on additional tasks associated with the
unexpected power outage.
√ Environmental Conditions – The anticipated heat in the hospital during the July
physical factors within the process power outage created a potentially life-threatening
environment that do or are environment for patients with respiratory
anticipated to impact performance conditions. Lack of power negated use of surgical
and/or process outcomes rooms. Medical and culinary processes were
disrupted. Other environmental and sanitary
conditions impacted many normal processes.
√ Unavailability of Equipment, Tools Inadequate backup generators, fans, cooling
or Documentation – constraints that equipment, medical equipment and other tools
impact the smooth execution of created a challenge for support personnel. Response
tasks to meet performance indicators teams were called upon to devise innovative plans
and process outcomes for assessing the short and long-term needs of
patients, out-patients and those scheduled for
elective surgery during the power outage period.

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Modular kaizen: Dealing with Disruptions Chapter 6
 Evidence–Based Research on Real-
Time Application - Missing best
practice information on successful
application of knowledge and tools
for implementation of performance
management

Cause & Effect Contingencies –

alternative approaches not identified
in advance for minor process
adjustments, either through
improvement or redesign
Organizational Cracks – work
delays; bottlenecks, missing/wrong
materials; poor downstream or
cross-functional communication; or
other similar barriers affecting
process performance
Unclear Policies – unclear or non–
existent policies conflict with
process performance; also where
policy directly contradicts a work
direction or intuitive action
Politics – politically expedient
actions cause conflict with efficient
performance to meet customer
requirements
Power & Accountability –
relationship and power issues with
functional leadership or stakeholders
that adversely affects process
performance. Issues with team
member accountability
Unclear or Conflicting Regulations
–standards or regulations create
conflict for correct and consistent
compliance during process
performance
Work Culture, Norms, and Values –
organizational culture interferes with
the efficient performance of process
tasks or negatively impacts process
outcomes
Figure 6.3: Association of Disruption to Areas of Concern Form
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Modular kaizen: Dealing with Disruptions Chapter 6
 How? Areas of Concern Disruption
Surgery scheduled Patients
Control
50% of needed capacity Generators
Use data to drive Audit
performance No Power in
Hospital
Increasing in hospital Temperature

Influence Response to situation Utility Co.

Make a bad situation Media

worse

Figure 6.4: Disruption and Impact Matrix – power outage scenarios

Figure 6.5 illustrates a Modular kaizen tool designed to engage those whose work is
disrupted in the resolution. Most high-performing professionals are self-organizing,
meaning that they expect to drive their work processes, not be driven by them. This
characteristic of self-organization is frequently observed in health departments.

Effective self-organization is supported by two critical elements: a clear sense of identity

and freedom. In organizations, if people are free to make their own decisions, guided by a
clear organizational identity for them to reference, the whole system develops greater
coherence and strength. The organization is less controlling but more orderly. Self-
organizing systems teach an important lesson about how change happens in living
systems. When the system is far from equilibrium (e.g. in disruption), singular or small
influences can have enormous impact. It is not the law of large numbers or critical mass
that creates change but the presence of a small disturbance that gets into the system and is
then amplified through communication networks. 5

Modular kaizen uses the inherent self-organizing tendency for knowledge workers to re-
balance disruption within their operating system. Small disruptions use the “check/act”
iterative process described in Chapter 3 to adjust processes continuously as evolutionary
changes occur. Evolutionary changes are generally supportive of the current goals and
strategies of the organization. In these situations, the traditional strategic planning
process can be used as a reference from which to analyze relevant data and to plan for
improvement of existing processes, products, or services.

5
Wheatley M. Leadership and the New Science: Discovering Order in a Chaotic World, 2nd ed. San
Francisco: Berrett – Koehler Publishers; 1999.
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Modular kaizen: Dealing with Disruptions Chapter 6
 Force & Effect + ca Chart
(c) - Capacity of Power Environment
Inhouse generators No Electricity
Temperature in Building
(c) – Check for hot spots Increasing

(a) – Secure fuel supply (a) – Shade windows

Current
(a) – Deploy Fans
Disruptive Stable
State: (a) – Secure ice supply State:
Massive Hospital
Power Operating
Outage Normally
Cases in rooms
(c) – Rooms without Power with no power
Discomfort
(c) – Determine
with heat
in Discomfort
(a) – Stop new
surgeries
Work with EMS
(a) – Transfer case (a) – Move to
(a) – Communicate cooler area (a) – Transfer
With relatives
OR – Patients
Operating Room

Figure 6.5: Force & Effect + ca Chart – power outage scenario

Contrasting with evolutionary change is revolutionary change. When the disruption

diverges radically from existing assumptions, more deliberation is required for resolution.
The revolutionary model requires the design of options for resolution which may not be
compatible with the traditional strategic direction of the organization. Barriers to change
are generally higher when change takes the organization and its workforce away from
their current comfort zone. The goal for revolutionary change is to identify alternative
solutions having either the most positive or least negative impact to the long-term success
of the organization. 6

One of the most successful techniques for helping people accept change is to involve
them in the change. Figure 6.5 illustrates a Force & Effect + (c)(a) Chart developed by
key leaders from each of the major hospital functional units. Leaders from facilities,
engineering, nursing, case management, and the executive offices came together after the
6:30 AM meeting to anticipate the areas of greatest impact to normal operations.
Providing a vehicle for the participants to express their concerns verbally reduced
tensions and focused attention on finding solutions, not complaining about barriers. The
actions identified during the development of the Force & Effect + (c)(a) form became a
task list of small “act” steps.

Once the response team defined the scope of the power outage and major impacts to
patients, staff, and other stakeholders, the next step was to generate a high-level picture

6
Beecroft D. Duffy G. and Moran J. The Executive Guide to Improvement and Change. Milwaukee, WI:
Quality Press; 2002.
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Modular kaizen: Dealing with Disruptions Chapter 6
of the response process. Figure 6.6 illustrates the SIPOC + CM created that clarified the
boundaries of the process. The SIPOC + CM form is the first step in process control. The
form guides discovery concerning suppliers, inputs, general process steps, outputs and
customers of the process. In addition, the form provides an opportunity to identify major
constraints to be addressed, as well as identification of realistic measures to ensure that
results are achieved.

Once the leadership and selected specialists within the hospital and community had made
a complete “check” of the current situation, response teams were employed to perform
small “act” functions to adjust normal operations to accommodate the power outage.
Because of the initial project management and process control steps taken by leadership
immediately upon disruption identification, the “act” steps were understood well enough
to be performed succinctly in parallel with monitoring patients and performing required
normal tasks.

High Level S I P O C + CM Form: Power Outage

Time before heat of day impacts patients, Ends With:
Constraints:
Availability of fans, mobile generators,
Begins With: Power restored,
subject matter experts, facility power
hookups, limited ability to transfer patients PDCA for
Major power stabilized process
outage in city
•6:30 AM status meeting
Process/Activities: Measures
•“check” on all current processes
•Hold press conference, send press release Power when/where needed
•Create check list of “check/act” reqt’s # patients impacted
•Transfer patients, adjust schedules Customer satisfaction
•Install mobile generator Staff satisfaction,
•Continuous monitoring documentation in place
•Full PDCA cycle, Document lessons learned

Outputs: Safe and secure patients, sufficient energy

Inputs: Information from power company
supply to meet critical need, adequate cooling
Mobile generator, fuel
Electrical materials, temperature monitors to meet care needs, satisfied relatives,
Fans, press release, risk analysis of losses, community leaders, public, updated check list
for future response, lessons learned and
patient requirements, communications
from community, etc. documented, up‐to‐date procedures

Suppliers: Customers:
Sr. Hospital Staff, medical/nursing staff, maintenance,
Patients, relatives, staff, Board of Directors, community,
Housekeeping, public relations, other H/C providers
senior management, city leaders
Mayor, governor, state police, subject matter experts,
equipment providers

Figure 6.6: SIPOC + CM defining the scope and high-level process for power outage

The key to fast transition of tasks is clear direction and understanding of the end result.
The small “act” steps performed by nursing, engineering, maintenance, and the executive
office were consistent with standard procedures within the hospital. The timing was
critical, as was the requirement to transfer some patients to other locations and reschedule
elective procedures until power was restored. Each of these tasks had been defined and
rehearsed previous to this unexpected outage. The hospital leadership employed “quality
at the source” by having all critical procedures defined, validated, and practiced before
they were needed in an emergency situation.

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Modular kaizen: Dealing with Disruptions Chapter 6
An example of the Operating Room response team plan is shown in Figure 6.7. The
operating room administrative staff did a “check” step to ascertain which rooms were
functional using direct power generators and scheduled any critical surgeries into those
rooms. An outcome of this “check” step was the realization that not enough local
generators were available to meet the needs of critical hospital functions. As described in
the scenario in Chapter 3, the response team alerted senior leadership, who arranged for
the mayor to secure an additional mobile generator from outside the city.

Disruption and Impact Diagram

Areas of Concern

c Disruptive Force

a
Disruption: Stable
Massive Current
Power Outage © Which rooms State
Have direct
Unable to use all OR rooms
generator
power

Use those
rooms
OR
(a)

Figure 6.7: Disruption and Impact Diagram for operating room response

The continued hourly senior leadership status updates provided additional small “act”
tasks that were integrated into the regular routines of the nursing, engineering,
housekeeping, facilities, and administrative staff. Figure 6.8 is a portion of the Disruption
form completed as a detailed outcome of the Force & Effect + ca chart shown in Figure
6.5. Once the high priority “act” requirements were identified by senior leadership,
functional response teams were empowered to analyze the specific requirements and
perform the small “act” steps to anticipate installation of the mobile generator sent from
the northern part of the state. Other response teams established a facilities temperature
monitoring schedule as part of the normal daily work management activities on the
hospital floors.

The Modular kaizen Disruption form is a modification of a standard risk management

form used in lean enterprise applications. This form is simplified to exclude the weighted
priority calculations of the more traditional Failure Mode and Effects worksheet. The
priority for action has already been established by senior leadership during the “check”
step previous to response team engagement.

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Modular kaizen: Dealing with Disruptions Chapter 6
 Modular kaizen Disruption Form
High Priority Barriers to Address

Process or
Hospital Power Outage Prepared by: Quality VP
Activity Name:

Responsible: President of Hospital Date (Orig) _7/8/2001______ (Rev) 7/ 13/2001

Process or How is the Disruption

What is the Disruption? Impact of Disruption Priority Potential Causes Actions Recommended Performance Measures Owner Actions Taken
Activity Step Managed Now?
PLAN DO
CHECK ACT

What are the existing What are the actions for What controls or Who is
What is the What is the impact on the How
controls and reducing the occurrence measures will responsible for What are the completed
process step/ In what way is the outcome (Customer severe is What causes the
procedures that prevent of the cause or effectively prevent this the actions taken to eliminate
activity under activity impacted? Requirements) or internal the activity to go wrong?
either the cause or minimizing the disruption from recommended the disruption?
investigation? requirements? impact?
disruption? disruption? recurring? action?

adeqiate reserves at Service level agreement with

Emergency need for distributor, logistics to fuel distributor, escalation
Electrical power No external electtricity No fuel for emergency Long standing contract Secure reliable fuel supply Facilities
High large increase in fuel for delivery fuel, local procedure for emergencies,
for the hospital available for 3 days generators with distributor Test escalation procedures Director
power generators storage capacity for alert process with power
cyclical requirement company

Some patients heat Checklist for patient

Inventory of fans, althernate Director of Check for hot spots, shade
Environmental intolerant, medications, Loss of power to cooling Montiroing of tempertures requirements, adequate
heat rising in facility High power source, transfer Nursing, Chief windows, secure ice supply,
control equipment need cool systems in facility and equipment inventory, alternate power
critical patients Engineer, CFO deploy fans, transfer patients
environment plan

Reschedule elective Reschedule surgeries,

Loss of external power, Stop new surgeries, 100% critical surgery
Cases in rooms with no surgeries, transfer critical OR admiistration transfer patients, close all but
Operating Room Rooms without power High lack of adequate transfer cases, coverage, accurae
power patients, move to OR with Director Ors with alternate power
alternate power communicate with relatives assessment of triage
alternate power source

Contact EMS to transfer

Hourly temperature patients, Contact other
Patient Heat intolerance by some Medical condition, age, monitoring, "check" on all Temperature, transfer Director of institutions, reschedule
Discomfort with heat High Fans, ice packs, transfer
monitoring patients personal decision patients during rounding, list, patient satisfaction Nursing elective surgeries, move to
escalation where appropriate cooler area, continued
monitoring

Figure 6.8: Modular kaizen Disruption Form – Prioritizing barriers addressed

The Modular kaizen Disruption form indicates activity related to a full Check-Act-Plan-
Do response cycle, including how the disruption is managed currently, actions
recommended to resolve the disruption permanently, performance measures to sustain
future outcomes, and actions taken in the short term.

The Modular kaizen Disruption form is the basic working document from which response
teams derive the requirements for action. The information gathered on the Disruption
form is used by the response team to generate small “act” steps that integrate efficiently
with the normally scheduled activities of the department. The intent of Modular kaizen is
to deconstruct a disruption to the extent that the cause is resolved by adjusting what is
already being done in the workplace. Where the impacted process needs more than
adjustment of normal operations, a work-around is identified for the short term, while
redesign efforts by subject matter experts are initiated.

The hospital leadership team successfully managed a major power outage in their facility
through fast assessment, engagement of the workforce, and effective communication with
outside resource partners. Although the short-term response was effective in reducing
temperature in the hospital and providing power to critical functions, a long-term process
needed to be established to error-proof the situation moving forward.

Figure 6.9 is the process map created once the power outage response was complete.
Once the pressure was off the organization, the response teams performed a full PDCA
cycle to create an efficient, stable process for handling major power outages. The process
map is the beginning of a series of detailed flowcharts for individual departments and is
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part of the process control element of Modular kaizen. Detailed flowcharts were the basis
of formal work instructions for electrical, facilities, maintenance, housekeeping,
medical/nursing, public relations and executive action. These flowcharts are not included
in this scenario. The detailed flowcharts are subject to frequent modification as daily
work management requirements are updated. Including one snapshot in time within a
long-term document is not appropriate.

Figure 6.9: Power Outage Response Process Map

One final yet critical document for standardization of performance management is the
Tri-metric matrix. This document ties the high priority actions to resolve a major power
outage with the ongoing performance management system of the organization. This form
analyzes the AoCs from the Disruption and Impact form illustrated in Figure 6.4. The
information included in the Tri-metric matrix is part of process control for long-term
sustainability of the improved set of processes for responding to a major power outage.

The Modular kaizen approach minimized the disruption to normal hospital operations
during a major power outage. The interaction of “check” and “act” steps based upon data
rather than emotion and the empowerment of the impacted workforce created an efficient,
effective response team effort. The short-term response that was successful although less
efficient than a carefully pre-planned process was sufficient to meet the needs of patients,
staff, and community. The follow-on design of additional Modular kaizen steps provided
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Modular kaizen: Dealing with Disruptions Chapter 6
a smooth flow of process redesign while subject matter experts engaged in their regular
responsibilities. Chapter 10, Daily Work Management, provides additional guidance on
integrating improvement activities into regularly assigned work schedules.

Tri-Metric Matrix: Power Outage

Tri‐Metric Indicator Definition Baseline Improvement
Target
1. Capacity: # Amperage/ Volts Amount of power Standard required Supplemental capacity
electrical available to service electrical output of available through hospital
equipment needs hospital requirement at connections to alternate
full patient load power sources

2. Capacity: •% Coverage All patient needs Standard, documented Checklist in place and
patient care •Cycle time to meet adequately covered, hospital performance rehearsed for anticipated
requirements rescheduled, or management service disruptions to normal
transferred to alternate levels service delivery environment
care provider

3. Process: •Degrees Fahrenheit Comfortable summer Normal summer Control any raise in
Temperature temperature of 75 temperature on patient temperature above 75
degrees in patient areas floors is on the average degrees on patient floors
75 degrees through alternative cooling
means

4. Outcome: % “top box” patient Percent of patient and Compared to national Attain greater than 80%
Satisfaction % “top box” staff staff satisfaction rated hospital survey data of responses above 75th
as “very satisfied” patient, staff ratings percentile ranking of
national survey data

5. Outcome: % critical patient care Amount of critical and Using industry Increase ability to provide
Service level completed to non‐elective patient accepted, documented non‐critical care at defined
requirements care delivered on time medical and audit service level
and within standards requirements

Figure 6.10: Tri-metric matrix: power outage scenario

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Modular kaizen: Dealing with Disruptions Chapter 6
 Chapter 7: Tri-Metric Matrix

Albert Einstein understood the difficulty of measurement when he said “Not everything
that can be counted counts and not everything that counts can be counted.” 1

Organizations spend a lot of time and money trying to obtain timely and relevant
information about their customers, markets, processes, employees, finances, and product
and service outcomes. They build elaborate dashboards and form committees to track
hundreds of measures and then wonder why they do not have any useful information
upon which to base important decisions. It is essential to have a process to convert data to
information and then to knowledge. Dr. Edwards Deming stated “Lack of knowledge . . .
that is the problem.” 2 Decision makers take data, apply statistical processes to it, display
it graphically, and convert it to knowledge to make decisions.

Organizations attempt to capture all relevant information on a situation of interest to

them; they think that information is knowledge. They indiscriminately go about amassing
information and measurements to “find out all there is to know.” This action wastes time,
effort, and money. When they eventually have all relevant information available, they
find that it is useless because it is not centered on a specific need. This gathering of all of
the information impedes planning and problem-solving by burying an organization in an
avalanche of irrelevant, unmanageable details. It leads to “analysis-paralysis.”

Furthermore, the information and measurements produce a sense of satisfaction about the
current situation. Just because all information is available, oftentimes people think that a
situation can be controlled. A former boss of one of the authors stated the foolishness of
this indiscriminate amassing of information many years ago when collecting data about a
process. He stated “We need to know what we are going to do with the data before we
actually collect it.” Unfortunately, his wisdom often goes unheeded.

The Limited Information Collection Principle of Breakthrough Thinking should be

applied in all instances when data gathering is necessary. The Limited Information
Collection Principle is based on the premise that a problem cannot be solved by throwing
data at it. The Limited Information Collection Principle is the opposite of the
indiscriminate amassing of information and measurements to “find out all there is to
know.” Finding it all out wastes time, effort, and money. It impedes planning and
problem-solving by burying the problem in an avalanche of irrelevant, unmanageable
details which usually lead to analysis paralysis.

1
BrainyQuote.com. Definition of Counted. http://www.brainyquote.com/words/co/counted148801.html.
Accessed October 19, 2010.
2
BrainyQuote.com. Talk: W. Edwards Deming. http://en.wikiquote.org/wiki/Talk:W._Edwards_Deming,
Accessed October 19, 2010. See Appendix A for an Introduction to the work of Dr. W. Edwards Deming.
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Modular kaizen: Dealing with Disruptions Chapter 7
Continually asking “what purpose could this information serve” before starting to collect
any data 3 and then gathering useful and relevant data according to the unique aspect of
the situation is essential.

Measurement is a key ingredient of any improvement program. To make lasting

improvements, everyone in an organization needs to understand how to measure and
monitor processes and be able to use that data and information to prioritize where
improvements need to be made. Improvement consumes scarce organizational resources
and should be focused at the most important and strategic needs of the organization.
Measurement helps to shift attention to areas of important needs.

The concept of Modular kaizen is dependent upon accurate measures to move effectively
through the planned steps of an improvement project. Organizing tasks within a Modular
kaizen project includes a possibility that one task may be performed and the next task left
to wait until the improvement team comes together again much later to pick up the
problem-solving and decision-making. Having a well-defined, organized matrix of
requirements provides a solid foundation for resuming effective operations after a
planned hiatus.

A Tri-Metric Matrix can be developed for most processes. The Tri-Metric Matrix helps to
guide the decision maker to measure the important aspects of a process’s capacity,
capability, and outcomes. When developing measures for a Tri-Metric Matrix, the
following questions need to be asked for each measure that is proposed:
 What is the measure measuring?
 What is the baseline for this measure?
 If no baseline exists, can one be obtained or developed?
 Will this measure help to understand how the process is functioning?
 Is the measure directly linked to the current strategy?
 Will this measure positively impact the process under study?
 Will the measure positively impact the customers if it is improved?
 Will employees have personal incentives to improve this measure?
 Are improvements in the measure likely to result in better service?
 Are the resources available for improving this measure?

3
Hoffherr G, Moran J, and Nadler G. Breakthrough Thinking in Total Quality Management. Englewood
Cliffs, NJ: PTR Prentice Hall; 1994.

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When developing Tri-Metric Measures for a process, the goal is to determine what
measures should be the Key Process Indicators (KPI). The following areas are some
guidelines for potential major KPIs.
 Effectiveness—Does the process output conform to stated requirements?
Goal: Doing the right things.
 Efficiency—Does the process produce the required output at minimum resource
cost? Goal: Doing the right things well.
 Quality—Does the output meet customer requirements and expectations?
 Timeliness—Does the process produce its output correctly and on time?
 Productivity—How well does the process use its inputs to produce its output?
Goal: Establish the ratio of the amount of output per unit of input.
 Output —How much does the process produce in a given time period?

Depending on the process in place, the KPI may be a combination of the above. It is
desirable to have proactive measures that show what is happening now in the process
rather than reactive measures that show what has happened. Whatever measures are
decided upon should give a clear indication of how the process is operating and should
indicate when action must be taken. This process is also displayed in Chapter 12 – Daily
Work Management.

Tri-Metric Indicator Definition Baseline Improvement

Target
1. Capacity
2. Process
3. Outcome

Table 7.1: The Tri-Metric Matrix

Table 7.1 shows the basic elements of the Tri-Metric Matrix. Three Tri-Metrics that
every improvement project needs to focus on are:

1. Capacity measures of the process under study. The capacity of a process is

defined as an output measure which is a measure of activity. Sometimes this
is referred to as the maximum output rate measured in terms of some type of
units provided per period of time. For example, ten customers can be
processed per hour in a clinic, 100 calls per hour can be processed in a call
center, eight surgeries per hour can be moved through an operating room
(OR), or 200 boxes of tissues can be made every ten minutes. Once the
maximum output rate of a process is known, then the capacity utilization or
the percentage of the maximum output that is currently being utilized can be
understood. Knowing that the OR has a 75% utilization rate for the past
three weeks can become useful information.
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Modular kaizen: Dealing with Disruptions Chapter 7
 Sometimes it is useful to understand activity measures which describe the level of
resources committed to a process. Just knowing these three measures does little to
help us understand how the process is satisfying our customers. Process and
output measures help us understand the capability of the process to meet customer
needs. Table 7.2 shows some typical capacity measures.

Tri-Metric Indicator Definition Baseline Improvement

Target
1. Capacity Output Rate Units/time 400/hour 450/hour
Capacity % of maximum 75% 85%
Utilization output utilized

Resources FTE, space, 40 FTE 30 FTE

Committed equipment, etc. 900 square feet 800 square feet
2. Process
3. Outcome
Table 7.2: Sample Tri-Metric Matrix

2. Process measures are descriptors of how the process is performing in its

current state. It is very important to understand how the current state is
operating and define the baseline before attempting any type of improvement
activities. It is important not to change a process before understanding where
it is centered or the amount of variation that is present. The most common
measures of a process are the mean and the standard deviation. Once those
measures have been calculated, conducting a capability study which
measures the number of standard deviations between the process mean and
the nearest specification limit in sigma units can occur. In general, as a
process’s standard deviation rises, or the mean of the process moves away
from the center of the tolerance:
 fewer standard deviations will fit between the mean and the nearest
specification limit
 an increased likelihood of items outside specification will occur
The two indices used in defining process capability are:
 Cp - Measures the variation - how well the data fits within the upper
and lower specification limits (USL, LSL) - width of the process
distribution relative to a set of limits
 Cpk - Measures the central tendency – it is an index which measures
how close a process is running to its specification limits and how
centered the data is between the specification limits.

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 The larger the index, the less likely it is that any item will be outside the
specifications. Table 7.3 shows some typical process measures.

Tri-Metric Indicator Definition Baseline Improvement

Target
1. Capacity Output Rate Units/time 400/hour 450/hour
Capacity % of maximum 75% 85%
Utilization output utilized

Resources FTE*, space, 40 FTE 30 FTE

Committed equipment, etc. 900 square 800 square feet
feet
2. Process Mean Mathematical
average of a set
of numbers.
Standard Measurement
Deviation of variability
or the square
root of the
variance
Cp How well the
data fits within
the spec limits
(USL, LSL)
Cpk How centered
the data is
between the
spec limits
3. Outcome
*FTE = Full-Time Equivalent Headcount
Table 7.3: Sample Tri-Metric Process Measures

In the service industries, healthcare, and public health, many processes do not have
defined specifications. For processes without defined specifications, it is important to
develop limits with the customers of the process variation that they will tolerate. The
authors propose developing an Upper Toleration Limit (UTL) and Lower Toleration
Limit (LTL) to allow use of either Run Charts or Control Charts. The questions to ask a
customer might be “How long are you willing to wait for the doctor, for a flu shot, to get
service in a WIC clinic, or to get a meal at a fast food restaurant?”

Since many customers understand that waits are inevitable, it is important to compile an
average from many customers on what would be the UTL on wait time. Everyone would
like zero wait time, but realistically people will accept a minimal wait. Defining that
minimal acceptable wait as the LTL is important.
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Modular kaizen: Dealing with Disruptions Chapter 7
As an example, our customers of the XYZ process have been surveyed, and they
indicated the following for wait time to get services: UTL = 15 minutes and LTL = 5
minutes.

A process capability study of this process shows its center and its variability. It is
possible to see if the process is capable of meeting customer wait time levels. If it is not,
improvements can be made to center the process so that it meets customer needs. This
approach could also be applied to cycle time and Process Efficiency Percentages.

3. Outcome measures are measures of the result of a process output. An outcome

measure is used to measure the success of a process. For most processes, an AIM
statement is developed to focus what the process is supposed to accomplish and
by when. Examples of outcome measures are:
 Achieving a Press Ganey score for patient satisfaction of 99%
 Reducing hemoglobin A1c (HbA1c) to less than 7 for patients with diabetes
 Healthcare acquired adverse event - < three surgical site infections
 300 accident-free days
 98% TB completion of therapy
 97% Medicaid billing success rates
 100% HIV regimen compliance
 < 5% Tobacco use by middle and high school students
 < 8 minutes clinic waiting time

Table 7.4 shows some typical outcome measures. Measurement is the key to having
processes that successfully deliver customer satisfaction. Measurement needs to build
outward from capacity to process to outcomes. These three measures must be aligned and
monitored on a regular basis to ensure that processes are running at maximum efficiency.

Measuring capacity, process, and outcomes gives three critical perspectives to the overall
performance of a process. Capacity dictates whether resources to meet current demand of
the product or service are available. Process allows the monitoring of the continuing
effectiveness of activities performed to create an acceptable product or service. Outcome
gauges the satisfaction of the end user with the product or service once it is delivered or
experienced.

The Tri-Metric Matrix is a tool which guides an improvement team through the steps of
identifying capacity requirements, process expectations, and outcomes for a product or
service. The value of this tool is more than a checklist for filling in customer or process
requirements. This tool prompts the improvement team to interact with customers,

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Modular kaizen: Dealing with Disruptions Chapter 7
suppliers, subject matter experts, and each other to understand enough about the overall
process to control it effectively.

Tri-Metric Indicator Definition Baseline Improvement

Target
1. Capacity Output Rate Units/time 400/hour 450/hour
Capacity % of maximum 75% 85%
Utilization output utilized

Resources FTE, space, 40 FTE 30 FTE

Committed equipment, etc. 900 square feet 800 square
feet
2. Process Mean Mathematical µ = 10 minutes µ = 8 minutes
average of a set of
numbers.
Standard Measurement of σ = 2 minutes σ = 1.5
Deviation variability or the minutes
square root of the
variance
Cp How well the data Cp = 2.0 Cp = 1.6
fits within the spec
limits (USL, LSL)
Cpk How centered the Cpk = 1.5 Cpk = 1.0
data is between the
spec limits
3. Outcome Customer % satisfied 98% score 99% score
Satisfaction customer
Accident-free # accident-free 300 days 350 days
days days
TB Patients completing 75% 95%
completion of therapy
therapy successfully

Table 7.4: Example Tri-Metric Matrix Outcome Measures

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Modular kaizen: Dealing with Disruptions
 Chapter 8: Standardizing and Controlling the New System

Once an improvement team has designed, piloted, and installed a new system, the process
must be stabilized. Process stability exists when the new process is in statistical control
and produces predictable results based upon customer expectations. Previous chapters
discuss the concept of process capability. It is assumed that when a new system is
designed and installed it is capable of producing the results desired by the patient, the
public health organization’s customer. Process stability should be determined during pilot
testing before final implementation is complete.

The goal of standardizing and controlling a system is to achieve operational excellence.

Operational excellence for an organization means that it has its business processes not
only standardized but also optimized to realize the organization’s strategic objectives as
quickly and efficiently as possible. Quality improvement (QI) tools support both
standardization and optimization. During initial design and testing of a new or improved
process, tools provide structure through which to analyze pilot process flow and outputs.
Since changes tend to destabilize processes, some tools are designed to gather data
created by the new testing environment. Once the improved or redesigned process is
stabilized, other tools are available to monitor ongoing process performance to sustain the
desired level of performance.

An organization needs to standardize processes to achieve operational excellence and

embed them across the entire organization. Best practices and higher performance must
be replicated in every operational unit. Optimizing at the unit level risks sub-optimization
at the system level. The PDCA cycle referred to in previous chapters has a counterpart
called the SDCA cycle – Standardize, Do, Check, and Act. Once the right change has
been designed, piloted, and approved through the PDCA cycle, the SDCA cycle keeps the
new process in control. First, one would implement the Standardize process, “Do” it
according to the setup designed, “Check” it through measurement to ensure that it is
performing correctly, and then “Act” if a variance needs correction. One returns to the
PDCA cycle if a major development occurs in customer demand, technology change, a
legislative mandate, a political impetus, or other external influence that disrupts the
process. These external influences generally require a significant analysis of current
operations with the possibility of process improvement or redesign. The integrated
PDCA/SDCA cycle is shown in Figure 8.1.

When standardizing a process, its stability and capability must be understood. “While
there is no direct relationship between process stability and process capability, there is an
important connection: Process capability assessment should only be performed after first
demonstrating process stability. If a process is unstable, we cannot predict its capability.
Any estimate of process capability we make depends entirely on where the process
happens to be when we collect the data. Suppose the process average is shifting about
over time. An estimate of the process capability is only reflective of where the process is

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Modular kaizen: Dealing with Disruptions Chapter 8
at that point in time, not where it may go next.” 1 All processes exhibit variation. Service
transactions and those processes influenced by the behavior of human beings rather than
machines tend to show more variation when statistically in control. Machines are
designed to repeat specific actions on a consistent basis. Human beings bring self-
awareness to the process, adding a significant factor of choice and interpretation to the
situation.

C
Figure 8.1: The PDCA/SPCA cycle

Variations are differences, usually minor, from the designed and expected outputs of a
process. Some variation is found in all processes. The key to controlling processes is to
control variation as much as possible.

All variation has some cause. Knowing the causes of variation is important in order to
determine the actions that must be taken to reduce the variation. It is most important to
distinguish between special cause variation and common cause variation.

Special cause variation results from unexpected or unusual occurrences that are not
inherent in the process. As an example:

A new clinic nurse is on her way to work in the morning when her car engine
stalls because of a fuel-line leak.

1
Wachs S. What is the relationship between process stability and process capability?
http://www.winspc.com/datanet-quality-systems/support--resources/what-is-the-relationship-between-
process-stability-and-process-capability.html, Accessed November 11, 2010.
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Modular kaizen: Dealing with Disruptions Chapter 8
This occurrence was not inherent in the normal work commute process. Special causes of
variation account for approximately 15 percent of the observed variation in processes.
They are usually very easy to detect and correct. While usually easy to detect and correct,
it is important to have processes in place so that special cause variations are actually
detected. These special causes are sometimes called assignable causes because the
variation that results can be investigated and assigned to a particular source.

Common cause variation results from how the process is designed to operate and is a
natural part of the process. As an example:

A new clinic nurse starts her morning commute on time, follows her normal route,
and arrives at the health department nine minutes later than usual but within the
overall time allowance of her schedule. She experienced a slowdown due to the
timing of traffic lights.

Common causes of variation account for approximately 85 percent of the observed

variation in processes. When the process is in control, as it was in the above example,
taking action may not be necessary. Making minor adjustments to a process because of
perceived common cause variation is called tampering. Tampering can drive a process
into further variation due to unnecessary changes made to a stable process due to a
perceived special cause that is actually a common cause. While common causes account
for 85 percent of the observed variation, “Fixing” pieces of the process can be time-
consuming and miss larger aspects of the process that may warrant adjustment.

Process owners should recognize that the special cause variations in quality within
production or service processes can usually be detected and removed by the individuals
who are operating the process. Common cause variations usually require management
intervention and action to change some inherent feature of the process. This is sometimes
called the “85/15 rule,” recognizing that management is responsible for providing the
necessary inputs to address and correct the majority of variation problems or common
causes. 2 Tools such as Check Sheets and Run Charts are useful in a wide range of
situations, including when a process under study is not yet stabilized. Other tools, such as
Control Charts, Paynter Charts, and error-proofing depend upon the process being
stabilized or in control before the data are reliable enough for decision making. Using
tools built for stable processes on out-of-control data is a recipe for failure.

Once a stable and capable process is installed, it must be monitored to ensure that the
process remains stable and capable. This chapter introduces the use of five QI tools for
process control. An excellent reference for information on the use of statistics in QI and
process control is Quality Control by Dale Besterfield. 3

2
Bauer JE, Duffy G, Westcott RT. The Quality Improvement Handbook, 2nd ed. Milwaukee, WI: Quality
Press; 2006.
3
Besterfield, DH. Quality Control, 8th ed. Englewood Cliffs, NJ: Prentice Hall; 2009.
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Modular kaizen: Dealing with Disruptions Chapter 8
Graphical charts are useful to monitor a process for any variation in performance. Visual
display of process data allows analysis for patterns not easily seen in numeric tables or
spreadsheets. The benefit of monitoring process performance data is to detect indicators
of change so that they can be acted upon and to communicate in a concise and visual
manner how a process is performing during a specific time period.

It is best to use the simplest graphical method to monitor a process. The method used will
be determined by the availability of data and the degree to which the process needs to be
controlled. All of these monitoring methods provide a dynamic visual view of process
performance. Numeric tables of data or comparison of summary measures do not offer
the same graphical impact as visual representations. The following five are a few of the
most common methods used either alone or in combination.

A checklist is a predetermined list of items, actions, or questions that are checked off as
they are considered or completed. This type of Check Sheet is a generic tool.
The checklist is best used when a process or procedure with many steps must be
performed repeatedly or when a process is done infrequently and might be forgotten. The
checklist is an effective tool at the beginning of a new activity or when a process with
multiple steps or lots of detail has been improved or redesigned. Providing a step-by-step
sequence of activities or identification of items to be accounted for hastens the
stabilization of a new process. When creating a checklist for steps of a process, it is
important to prepare a flowchart first to determine the steps and their sequence.
Prepared checklists are widely available. Checklists that will guide the work of a
response team can be found in books about teams or in final reports of health department
QI projects. 4 Figure 8.2 is an example of a checklist used by Duval County
Immunization Clinics in Jacksonville, Florida.

Closely related to a checklist is a Check Sheet. A Check Sheet is a form used to record
the frequency of specific events during a data collection period. A Check Sheet is a
simple form used to collect data in an organized manner and to convert it into readily
useful information. The most straightforward way to use a Check Sheet is to make a list
of items expected to appear in a process and mark a check beside each item when it does
appear. This type of data collection can be used for almost anything from checking off
the occurrence of particular types of defects or the counting of expected items (e.g., the
number of times the telephone rings before being answered).

Various innovations in Check Sheets are possible. Using a map of the community
supported by the health department could be the Check Sheet. The idea in this Check
Sheet is for the user simply to mark on the map the location of each septic system
inspection that is made. The map becomes a very effective graphical presentation of
where new or repaired septic systems are. Another name for this type of Check Sheet is a
“measles chart.”

4
Tague NR. The Quality Toolbox, 2nd Ed. Milwaukee, WI: Quality Press; 2004.
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 Immunization Checklist for the Clinics

√ Front Desk

 Register patient in HMS

 Cross Check for duplicate patients

 Access FL Shots for Patient Information “Search FL Shots”

 Ask for address, phone number, and email address (change
information if necessary)

 Import updates to HMS

 Make sure you have selected the proper Current
Immunization Provider (CIP) status is correct in FL Shots

 Print Immunization History from FL Shots attach to

Superbill/Chart along with Insurance verification
Staff Signature
√ RN/LPN/MA/HST

 Greet patient
 Assess for needed vaccines
 Explain vaccines to be given today
 Give VIS to patient/parent
 Ask for any questions
 Give Injections
 Explain after care instructions, invite questions
 Document immunization in Florida Shots
 Give patient an updated record of shots w/new due date
 Tell patient when to return for next vaccinations
 Document in medical records
Staff Signature
√ Billing Clerk

 Process Superbill

 Process any collections

 Ask did you get your updated record of shots?

 Release Client
Staff Signature

Patient Label

For more information, email [email protected]

Figure 8.2: Immunization Checklist for Duval County Health Department Clinics 5

5
Duval County Health Department, Jacksonville, Florida. 2011.
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A Check Sheet may be used to:
 Collect data with minimal effort;
 Convert raw data into useful information; and
 Translate opinions of what is happening into what is actually happening.

The basic steps involved in creating a Check Sheet are:

1. Clarify the measurement objectives. Ask questions such as:
 "What is the problem?"
 "Why should data be collected?"
 "Who will use the information being collected?"
 "Who will collect the data?"
2. Create a form for collecting data. Determine the specific things that will be
measured and write this down the left side of the Check Sheet. Determine the time
or place being measured and write this across the top of the columns.
3. Label the measure for which data will be collected.
4. Collect the data by recording each occurrence directly on the Check Sheet as it
happens.
5. Tally the data by totaling the number of occurrences for each category being
measured.
6. The data from the Check Sheet can be summarized in a number of ways, such as
with a Pareto chart or histogram. Another analysis approach for data from the
Check Sheet is through the run and Paynter Chart described below. 6
Figure 8.3 is an example of a Check Sheet.

Run Charts are charts showing how a process performs over time. It is a simple line
graph that depicts a running record of process behavior over time. The running record is a
chronological plotting of the data points that show the sequence in which process events
occurred. These data points can represent measurements, counts, or percentages of
process output. This chronological plotting enables the visualization of how the process is
performing and whether it is stable. The run chart helps pinpoint indicators of special
causes of variation. Figure 8.4 shows a typical run chart with a median line displayed that
divides the data into two equal halves. The median is the middle value in the data we
have collected to plot the run chart.

6
Bauer JE, Duffy G, Westcott RT. The Quality Improvement Handbook, 2nd ed. Milwaukee, WI: Quality
Press; 2006.
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 Type of April 23 April 24 April 25 April 26 April 27 Total
Defect Defects
Illegible IIIII IIIII IIIII II IIIII IIIII IIIII IIIII IIIII IIIII
71
Address IIIII IIIII I IIIII III IIII I
IIIII I II IIII IIIII IIIII
Wrong State 22

Wrong Zip IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII
59
Code IIIII IIIII III II
Bad Office III IIIII I III IIII
16
Symbol
Total
50 19 36 34 29 168
Defects

Figure 8.3: Check Sheet tallying number of misplaced letters by reason

A plot of data over time will reveal information about a process under study. Some data
patterns such as the following may be observed from a Run Chart:
 Trends
 Mixtures
 Outliers
 Cycles
 Instability
 Sudden Shifts
Measurement

x
x x
x x
Median Line
x x
x

Time

Figure 8.4: Run Chart showing measurements over time

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These data patterns are some of the more common ones observed on Run Charts and are
by no means all of the patterns that could be observed. When viewing and interpreting a
Run Chart, variation will be observed in action since all processes have variation.
Observing any trends, runs, or cycles that indicate the presence of special causes and
indicating that a special cause could be present in addition to the Theory of Runs help us
analyze the nature of the variation. 7 One example of the Theory of Runs is a sequence of
seven or more data points steadily increasing or decreasing with no change in direction.

When analyzing a Run Chart, it is essential to blend knowledge of the process with the
data displayed to see if a conflict exists between the outcome expected and actual
performance of the process. Investigate any conflict or disruption. A listing of conflicts
between expectation and reality or observable disruptions can lead to improvement
opportunities. Focus on and understand any unusual patterns, shifts, cycles, or bunching
of data points and verify if they are real. It is important to verify if the pattern is real since
it may be a signal of a special cause that needs further investigation. Before time and
resources are expended on improving a special cause signal, it must be verified.
The absence of signals of special causes does not necessarily mean that a process is
stable. Quality specialists suggest that a minimum of 100 observations without an out-of-
control signal are required before a process can be labeled as in statistical control.

The Paynter Chart 8 was developed by Marvin Paynter, a quality engineer at Ford Motor
Company, when he wanted to show a number of issues from different sources of inputs
on a one- page tool as a summary for management. His idea was to pull together the Run
Chart and Pareto data 9 into a single chart. The Paynter Chart can show emerging and
declining problems, the timeframe for any corrective action and its effects, and whether
or not the corrective action provided acceptable results.

The Paynter Chart is a graphic tool that displays the history of a problem or opportunity
over time. It can be used to monitor and track several different areas of an opportunity or
occurrence of failure and highlight or show the impact of any changes or corrective
actions over an extended period of time. Ideally, and to get a view of the history of a
problem, the chart should show the prior few months, six if possible, and at least three to
six months into the future. This visual of the timeframe for action and responses is more
complete and informative.

7
Evans JR, Lindsay WM. The Management and Control of Quality, 6th ed. Mason, OH:
Thompson/Southwestern; 2005.
8
Munro R. Paynter Chart. American Statistical Association Detroit Chapter Newsletter. August, 1995.
9
A Pareto Chart is used to focus efforts on the problems that offer the greatest potential for improvement
by showing their relative frequency or size in a descending bar graph.
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Modular kaizen: Dealing with Disruptions Chapter 8
The information on the Paynter Chart is developed from the Pareto analysis, the bar chart,
the Run Chart and a table record/tally chart of measurements or events tracked over time.
It demonstrates the following functions:
 Identifies new and reducing problems;
 Shows the effects over time of any changes made;
 Can correlate actions taken to any changes in results, acceptable or unacceptable;
and
 Validates effect of changes over time.

While the Run Chart shows a plot of measurement over time as single data points, each
of those data points can have a number of items rolled up into it. The Paynter Chart
allows us to click on a data point and see what is composing it as shown in Figure 8.5.
The bold boxed summary point is composed of data from T, X, Y, and Z which are
displayed in the Pareto Chart. From the Pareto Chart we can determine the percent of
contribution of each of the subdata to the total.

The Paynter Chart should be constructed as the data tally sheet is created for the Run
Chart since this practice will simplify the calculations later. This combination of Run and
Pareto Charts provides a comprehensive visual for presenting a process’s performance.

x
x x
x
Median Line
x x
x
%

T X Y Z

Figure 8.5: Paynter Chart combining Run Chart and Pareto Chart

Control Chart - While every process displays variation, some processes display
controlled variation that is natural to the process (common causes of variation). Other
processes display uncontrolled variation that is not present in normal operation of a stable
process (special causes of variation).

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Modular kaizen: Dealing with Disruptions Chapter 8
The Control Chart is similar to a Run Chart since it is a graph used to study how a
process changes over time. Like a Run Chart, data are plotted in time order. The
difference between the Run Chart and the Control Chart is that the Control Chart always
has a central line for the Average of the data plotted and not the Median of the data that a
Run Chart calculates. The Control Chart is more complicated than a Run Chart since it
has calculated upper and lower control limits. These control limits are determined from
historical data. By comparing current data to these lines, conclusions can be drawn about
whether the process variation is in control or is out of control, affected by special causes
of variation. If the process is in control, reliable predictions about its output can be made.

Figure 8.6 shows a typical Control Chart with the average (mean) and control limits
displayed. Some Control Charts show warning lines to alert when the process is
approaching an out-of-control value. The warning line is shown in Figure 8.6. A Range
Chart is frequently calculated with a Control Chart to reflect the span between the highest
and lowest values of the data averaged to plot the individual points on the Control
Chart. 10

UCL
Measurement Scale

Average

LCL

Data Plotted In Time Ordered Sequence

UCL: Upper Control Limit

LCL: Lower Control Limit

Figure 8.6: Control Chart showing averages of sample data plotted in time-ordered
sequence

10
A detailed explanation of statistical control is beyond the scope of this text. The reader is referred to a
standard statistics text.
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Rules for detecting "out-of-control" or non-random conditions were first postulated by
Walter A. Shewhart in the 1920’s and became known as the Western Electric Rules. 11
Lloyd S. Nelson developed the Nelson Rules 12 to help guide the interpretation of Control
Charts which were similar to the Western Electric rules. A general summary of the Out-
of-Control Rules is shown in Table 8.1.

Any Point Above The UCL

UCL
2 – 3 Points in this area or above
Measurement Scale

4 – 5 points in this area or above

8 points in a row in this area or above
Average
8 points in a row in this area or below
4 – 5 points in this area or below
2 – 3 Points in this area or below LCL
Any Point below the LCL

Data Plotted In Time Ordered Sequence

UCL: Upper Control Limit

LCL: Lower Control Limit

Figure 8.7: General rules for out-of-control process conditions within Control
Charts

Many types of Control Charts for variable data, attribute data, and special circumstances
exist. Quality Control by Dale H. Besterfield is an excellent resource for entry-level QI
team understanding of basic statistics, run, and Control Charts. 13

Control Charts are used to:

 control ongoing processes by finding and correcting problems as they occur;
 predict the expected range of outcomes from a process;
 determine whether a process is stable and in statistical control;
 analyze patterns of process variation from special causes or common causes; and
 determine if a QI project should aim to prevent specific problems or to make
fundamental changes to the process.
11
The Western Electric Rules were codified by a specially appointed committee of the manufacturing
division of the Western Electric Company and appeared in the first edition of its Statistical Quality Control
Handbook in 1956.
12
Nelson LS. Technical Aids. Journal of Quality Technology. 1984; 16(4): 238-239.
13
Besterfield, DH. Quality Control, 8th ed. Englewood Cliffs, NJ:Prentice Hall; 2009.
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When analyzing a Control Chart, as suggested for the Run Chart, blending knowledge of
the process with the data displayed to see if conflict between the outcome expected and
actual performance of the process is evident is a solid start. Next, it is important to
investigate any conflict or disruption. Creating a listing of conflicts between expectation
and reality or observable disruptions can lead to improvement opportunities. Focusing on
and understanding any unusual patterns, shifts, cycles, or bunching of data points and
verifying if they are real are crucial next steps. It is important to verify if the pattern is
real since it may be a signal of a special cause that needs further investigation. Before
time and resources are expended on improving a special cause signal, it must be verified.

Is the Control Chart you are using healthy?

Does it include relevant information to help gain insight about your process?

Control Charts are valuable tools to help a response team implement fundamental process
changes to improve patient care. Before the team can effectively utilize the information
from the chart, they must first be confident that the chart being reviewed is healthy. Just
as a physician would not perform elective surgery on a patient with an infection, the team
should not analyze a process improvement chart without first considering seven key
attributes.

Software is an invaluable tool for creating Control Charts; however, great diversity
among software programs exists. When choosing Control Charting software, using these
seven traits as a guide will be effective:

1. Lloyd Nelson limits for computing Control Charts

2. Clear, extensive, and accurate titles
3. Underlying data visible on the chart
4. Control limits reflect process change
5. Out-of-control conditions clearly identified
6. Assignable causes shown but not used in overall calculations
7. Annotations used to increase understanding

Error Proofing - focuses on two aspects of process activity: (1) prediction, or

recognizing that a defect is about to occur and providing a warning, and (2) detection, or
recognizing that a defect has occurred and stopping the process. Human beings tend to
make mistakes inadvertently. Typical mistakes in daily work or when providing service
to customers are omitted process, processing errors, setup errors, missing information,
wrong information or adjustment errors.

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Such errors can arise from the following factors:
 Forgetfulness due to lack of concentration
 Misunderstanding because of the lack of familiarity with a process or procedure
 Poor identification associated with lack of proper attention
 Lack of experience
 Absentmindedness
 Delays in judgment when a process is automated
 Equipment malfunctions 14

Other terms for error proofing are “mistake proofing” and “Poka-Yoke,” a Japanese term
coined in the early 1960’s by Shigeo Shingo, a twentieth century Japanese industrial
engineer who distinguished himself as one of the world’s leading experts in
manufacturing practices. 15

Blaming the worker not only discourages them and lowers morale but also does not solve
the problem. Many applications of error-proofing are deceptively simple yet creative.
Usually, they are inexpensive to implement. The checklist in Figure 8.2 from Duval
County, Florida is an example of error-proofing. The Check Sheet provides a sequential
guide to all of the steps required during a customer engagement in the Immunization
Clinic. By following the Check Sheet and marking off each step as completed, the clinic
professional is alerted by the next unchecked item that it is the next step to be performed.
At the end of the clinic visit, the same Check Sheet can be used to audit daily volume
within the clinic and completion of all required steps in each process supported by such
Check Sheets.

Modular kaizen uses the concepts of control and standardization to identify Areas of
Concern and disruption. Performance management, based upon the department’s strategic
plan, sets the foundation for critical measures that reflect required organization and
community outcomes. Using standards set for the health department during its regular
planning cycle ensures that comparison of activities performed to required outcomes
closely matches the department’s mission and objectives. The more aligned response
teams are to priority outcomes of the health department, the more efficient they will be in
choosing process improvement projects. The benefit of keeping the “check” and “act”
process directly related to priority activities is that the tasks performed blend easily with
the daily work of the response team members. Fast transition is an element of the House
of Modular kaizen. Response teams are able to transition quickly from normal work tasks
to improvement tasks because the skills and information required for improvement are
closely related to what they are doing in their normal work assignments.

14
Evans JR and Lindsay WM. The Management and Control of Quality, 6th ed. Mason, OH:
Thompson/Southwestern; 2005.
15
Wikimedia Foundation, Incorporated. Wikipedia: The Free Encyclopedia.
http://en.wikipedia.org/wiki/Shigeo_Shingo. Updated February 27, 2011. Accessed February 27, 2011.
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 Chapter 9: Change Management

If you want to make enemies, try to change something.

Woodrow Wilson

Organizations wanting to adopt the Modular kaizen approach need to have a culture that
can support and produce quick and rapid change; they must be ready to embrace constant
change and continuous improvement towards a defined standard of excellence that is
continually rising. This chapter gives leaders a road map to position their organizations
for ongoing and rapid change.

A common question asked by leaders and employees in various organizations is “Why do

we need to change our organizations on a regular basis? We like the place the way it is!
Why keep changing all of the time?” The answer is simply that the old ways of
accomplishing an organization’s purpose are not effective and efficient and do not work
any longer in the current environment. In today's rapidly changing organizational and
business environment, most organizations and their leadership realize this problem too
late.

Change is critical to the survival and sustainability of public health organizations.

Unfortunately all organizations have “antibodies” that resist change and challenges to
their legacy. These antibodies drive out new ideas and people that are considered either
odd or at odds with the organization’s current existence. These antibodies want to
maintain the status quo at all costs.

Most organizations do not change in response to seeing what is on the horizon and
wanting to prepare to meet the new challenges. Organizations change because they are
forced into it kicking and screaming by the aggressiveness of their competitors, political
or fiscal changes, or by their customers. Few organizations change because they have
visionary leadership that is able to foresee a shifting and sliding marketplace and position
their organization for the next market momentum move. These leaders understand the
Triggers of Change and the Four Variables of Successful Change. 1 Leaders want to know
what and how much to change and when. The Triggers of Change and the Four Variables
of Successful Change at different levels of intensity are shown in Figure 9.1. The
intensity levels require varying levels of effort and investment of scarce resources. When
making an investment in change, one needs to be cautious and try to minimize the risk of
failure. The best change is one that minimizes the intensity of the Four Variables of
Successful Change, thus reducing the stress and strain on the organization undergoing
change. For instance, it is preferable for change to occur without maximizing

1
Parts of this chapter are based on a previous work: Mead J, Moran J. TECHNOSPEED Change. The TQM
Magazine. 2001; 13 (4): 224-231.

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management involvement, resistance, degree of change, and resources. This approach
optimizes the possibility of successful change.

The Four Variables of Successful Change

Low Management Involvement High

High High

Trigger II Trigger IV
Resource Commitment

Resistance to Change
Change The Way We Function Change The Way We Do Business

Trigger I Trigger III

Change The Way We Work Change The Way We Interact

Low Low
Minor Major Radical
Degree of Change
Figure 9.1: The Four Variables of Successful Change

Change has always been ubiquitous. In the past, the luxury of changing at a leisurely and
more controlled pace was possible. What would once have been a long process of
changing a culture now has to be a shortened process; the organization might disappear if
it takes too long to change. Today the rule is “Change Quickly, Change Often, or Cease
to Exist.” The organizational culture must be able to support constant change.

Why have past change efforts not been successful?

In the past, the “Water and Wait” philosophy of change was common. The training and
consulting companies would dictate that the “process” was important; given enough time,
it would deliver the desired results. Organizations quickly lost patience with "Water and
Wait" change methodologies. Not many organizations reaped the benefit of “Water and
Wait.” It used to be that people had to be sold on change. In today’s fast-paced world,
the options are either change or be passed by. Change is a core competency for even the
most basic of jobs. Organizations often need to be prescriptive when change needs to
occur as to how soon it will be implemented and accomplished. This prescriptive
approach helps employees understand the importance of change to the organization and
for the benefit of its customers.
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Simply training people on how to change will not achieve the desired results because the
whole organization never reaches a point where everyone is trained at the same level and
at the same time. Oftentimes, it is not affordable to stop work and train everyone. Some
organizations adopt the imbedded Change Agent approach where selected individuals are
trained in the philosophy of change and then dropped into the organization to make
miracles happen. These embedded Change Agents soon find that without all of the Core
Ingredients as shown in Figure 9.2—power, authority, interpersonal skills, and
commitment—they become quickly frustrated. When someone who has no authority or
power is invited in to help an organization, it is important that someone from within that
organization becomes the imbedded change agent who can further the assistance; instead,
the person in the organization often watches the usual pattern develop of a cluster of
trainings, assessments, and change targets set to be implemented. Then the reality sets in
that the organization being assisted has other priorities not related to the change
envisioned; meetings get canceled, follow-on trainings get postponed, change targets slip,
and the imbedded change agent gets frustrated and ultimately gets blamed for the failure.
Simply stated, in the absence of leadership and organization-wide commitment to change,
a Change Agent’s success will be limited.

Core Ingredients and Dimensions of Change

Low Authority High
High High

Fast Burn Out The Complete Leader

Interpersonal Skills

Commitment
(Imbedded) “Change Agent”

Water and Wait Push Agent

(Process) (Dictator)

Low Low
Low High
Power

Figure 9.2: Core Ingredients and Dimensions of Change

Real Change Agents have all four Core Ingredients of Change at the highest level, and
they lead change by example in their areas of responsibility. If leaders lack interpersonal
skills and commitment, they become push agents; since they have been told to lead the

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change because of their position, they typically do not believe in it. Push agents achieve
some limited degree of success initially, but then those employees whom they lead soon
stop listening and acting since they see that leadership is not really committed or
engaged.

Once a true organizational change effort gets started, an effective way to train all of the
people on how to change is on-the-job training. Teaching and showing them how to
change by doing a little change all of the time is most beneficial. Individuals become
great Change Agents when they are actually practicing changing on a regular and
consistent basis. Change has to be led; it cannot be delegated.

How does an organization approach constant change?

Successful organizations approach change by constantly reinventing themselves, thinking

ahead, and making minor changes so that they are always positioned for the next wave of
change in the marketplace. This way employees view change not as a strange
phenomenon to resist but as one to embrace and not fear. It is important not to make
everyone an agent of change within the organization. Simply developing Change Agents
skilled only in the philosophy of change wastes resources since they usually have never
actually implemented change but have only talked about it in the abstract. Putting
employees through two to three days of mock exercises of change working on
hypothetical issues also is likely to have little, if any, lasting impact. In both cases, no
link to reality is evident; nothing beats doing it for real. Saving “Water and Wait” training
and consulting dollars and investing them in the first three Triggers of Change will help
to lower the resistance to the fourth Trigger of Change—“The way we do business.” This
approach has a higher potential return on investment.

What behaviors can leaders use to support change on an individual level?

At the end of each week, the leadership and employees of an organization should be
asking themselves “How have we changed this week? How must we change next week?”

Leaders can encourage potential change innovators to emerge and the early adopters of
change to continue by nurturing, facilitating, and protecting creative and worthwhile
change ideas in addition to appropriate responses to change. Leaders can provide this
support by standing behind the creative employee’s ideas, finding resources within the
organization to put their subordinates’ new ideas into action, and publicly recognizing
individuals who exhibit the organization’s preferred response-to-change behaviors. When
leaders fail to support and find resources for new ways of doing business, these ideas and
adaptive behaviors can wither and die before their potential benefits are ever considered
and before others can observe and emulate the early or successful adopters of new
changes. Without visible leadership support, any change program will be viewed as just
another top management fad to be waited out until it disappears.

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When must a consistent and sustainable change effort be initiated?

Does an organization wait for disaster or have foresight? The Four Triggers of Change
shown in Figure 9.1 are arranged in four quadrants, bound by the Four Variables of
Successful Change at different levels of intensity. The Four Variables of Successful
Change—Management Involvement, Degree of Change, Resource Commitment, and
Resistance to Change—are elements that need to be thought through in advance of
starting any change effort, defining how much can realistically be accomplished and in
what timeframe.

The fourth Trigger of Change, “Change the Way We Do Business,” is a total

transformational cultural change and the most difficult to accomplish in a short
timeframe. Often when a more intensive Trigger of Change occurs, organizations shoot
themselves in the foot. When an organization undertakes radical and quick change, it is
usually as a knee-jerk reaction to being caught flat-footed in a changing marketplace or
surprised by a competitor that is fierce and flexible. Massive upheaval usually results.
The resistance to the change internally is high and sometimes rebellious. Management
must heavily involve itself in making the change and patching up the mistakes caused by
engaging in this massive change, possibly defending itself against charges of
incompetence. The philosophy that is espoused is to link the organization quickly to a
new vision and possibly a new business model that may or may not be well-devised. Thus
the possibility of successful execution of a Total Transformational Cultural Change is
small, and very few organizations do this well.

The fourth Trigger of Change is the only level where all Four Variables of Successful
Change must be at their maximum level of intensity. Running four activities at their
maximum level and expecting them to mesh and turn out the desired result typically is
more wishful thinking than reality. At least one or two of them will have a misstep and
throw the rest out of synchronization. When this happens, the desired goal is not capable
of being reached, much less effort or loss recouped.

Organizations have better success with change if they use the other three Triggers of
Change since the Four Variables of Successful Change are at different levels of intensity;
some are low, and some need to be high. The odds of success are higher when only one
or two variables that need to be maintained at high intensity levels are in place.

The first type of change, or first Trigger of Change, may result from a desire within the
organization to seek small and continuous improvements. These changes typically are
more gradual and less overarching. All Four Variables of Successful Change function at
their lowest levels of intensity. When this occurs, each part of the organization is making
gradual and continuous improvement in the way that it works and is a great way to train
individuals in how to change. This on-the-job employee basic-level change training
works.

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The second Trigger of Change may result from a desire within the organization for
structural change that will affect the organization’s functions. This type of change has
Resistance to Change at its highest level of intensity and Management Involvement at a
low level of intensity. This change can be accomplished quickly since it usually is a
reorganization that can be isolated to specific departments and business units. Usually the
resistance is confined to a specific area in the organization and can be controlled and
monitored. The Resistance to Change may be isolated to a few individuals that can be
coached or consulted into joining the effort. This type of change happens whenever
certain functions are no longer needed, the organization needs to be flattened, a key
manager or employee leaves, a business unit is sold, or a product or service line is
discontinued. Such change is healthy for an organization in the long run since it
repositions the organization to focus its employees and resources on new tasks or new
businesses for the future.

The third Trigger of Change may result when a need and desire for change in the way
people interact within the organization is evident. This type of organizational behavior
change has the Degree of Change and Management Development at their highest levels
of intensity. This type of change involves having a very clear philosophy statement of
why it is necessary to change the way employees interact and support each other in the
organization. This new philosophy of change could be a new mission, vision, values, or
goals for the organization. The degree of change is high since people will be required to
act and behave in entirely different ways in order to meet the new goals in the
organization.

If organizations are constantly working on the First Trigger of Change and are
occasionally making Trigger Two and Three Changes, they will, in effect, accomplish a
Level Four Change in an organized manner over time while reducing the stress on the
organization that a complete level four radical transformational change entails.

How are organizations and their employees best engaged in supporting a successful
change effort?

Once a Trigger of Change is embraced, it is important to engage everyone fully in the

change effort. Figure 9.3, the “Change Commitment Spectrum,” shows steps that the
organization and the individual can take; these steps increase the likelihood of a
successful change effort.

When a change effort begins, both the organization and individual employees struggle
with the Translation Spectrum shown in Figure 9.3. The Translation Spectrum introduces
stress and anxiety into an organization. This stress and anxiety result from an
organization not completely defining what it is trying to achieve with its change effort. If
the concept of “what change will accomplish” is not clear and compelling, then the
individuals in the organization cannot envision what the end state will be and how they fit
into that picture. When individuals cannot picture a future reality that clearly includes
them in the “Big Picture,” they begin to feel stressed and anxious. Successful change
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results when an organization helps its employees move seamlessly through the
Translation Spectrum. Concept to reality is easier when the end state is clearly defined
rather than one that each individual interprets differently.
Change Commitment Spectrum

Organization Individual
High Organization High Concept
Low Individual Low Reality

Step 1. CATALYST Step 3. CAPACITY

Commitment To Change

Translation Spectrum
• Cause • Experience
• Why • Assessment/Needs

Step 2. RESULT Step 4. SKILL

• Output • Capability
• Expectation • Development/Training

High Individual High Reality

High Organization Low Concept

Figure 9.3: Change Commitment Spectrum

What strategies decrease stress, anxiety, and tension in individual employees? Four
primary questions need to be answered to an individual’s satisfaction before they can
even attempt to “give it their all” when faced with change. The individual can answer the
first two questions; the organization and its leadership answer the last two questions.
1. Do I have the capacity (experience) to change?
2. Do I have the capability (skills) to change?
3. What is the change that is wanted?
4. What is the expectation of results to be achieved?

All four questions need to be addressed to all parties’ satisfaction to ensure that they
wholeheartedly move with the change. If any one of the answers is perceived as unclear
or threatening according to the individual, then the person will be less likely to move with
the change and more likely to hesitate, work at partial speed or energy, sabotage the
change, or simply not participate in the change. The likelihood of successful change
decreases quickly when the individual perceives more than one answer to these questions
as threatening, unclear, or negative.

Organizational imperatives explain the “what” and the “why” of change to an employee.
While organizations are improving their ability and consistency in addressing these
issues, the individual imperatives that speak to “how” the change will occur are often

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assumed or overlooked. One only need look to Maslow’s Hierarchy of Needs 2 to
understand that the individual’s perceptions are the root of greater anxiety and stress and
are the more common and frequent reasons why change efforts are not successful in
organizations.

Consequently, when addressing the capacity for change, it is essential to look to past
individual and organizational experiences. How much change have they experienced?
What types of changes have occurred? How have individuals and groups reacted? As a
first step towards a proactive stance, management needs to determine how small changes
can be built into the daily, weekly, and quarterly regimen of individuals and workgroups
(e.g., national workgroups, teams, etc.). In many cases, these changes are occurring now,
but the capability to handle them rapidly with an economy of energy while productively
requiring that a singular focus be put on what is happening, how people are reacting, and
what the expectations are for output is crucial.

How do you really accelerate change?

Individual behavior provides us with four signposts for rapid and successful change.

Signpost 1: Usually, a catalytic event provides the energy or impetus to change.

Without the pain or anticipated pain of a catalyst, the necessary commitment energy
often is not present to drive through the discomfort of change.

Signpost 2: Next, the individual forms an image of a better; future state as an

antidote, or alternative, to the flawed status quo condition. Again, without the
promise of substantial improvement, the initial energy required for successful change
does not exist.

These first two signposts are fairly conceptual in nature. They set the stage for the next
two signposts by building the urgency, energy, and commitment needed to take personal
action and commit individual resources. Successful framing within these first two
signposts is not a guarantee that change will be implemented or successful, but the
absence of one or both is a strong predictor of failure or flawed change.

Signpost 3: Capacity consists of the individual taking stock of his/her own current
knowledge and resources and performing a gap analysis between present capacity
and the ideal future state. Also, it is important to decide what information, skill, or
ability is needed to determine a new course of action and ensure that it will be
successful. The individual compares the present state to the ideal future state and
determines what is needed to bridge the gap.

2
Maslow A., Lowery R. (Ed.). Toward a psychology of being (3rd ed.). New York: Wiley & Sons; 1998.

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 Signpost 4: Finally, the individual fills the gaps between the status quo and the
future ideal state with skill development, knowledge, practice, training, and
application. These actions facilitate the move from flawed status quo to the future
ideal state as the new reality.

The latter two signposts are concrete, action-oriented, and increasingly labor-intensive.
The chance for failure, errors, mishaps, recriminations, second-guessing and other
various forms of personal pain and discomfort all exist here with higher possibility and
probability. Consequently, an individual requires the most support with these steps.

The interrelationship of the Four Triggers of Change, Variables of Successful Change,

and the Change Commitment Spectrum are shown in Figure 9.4. In each quadrant of
Figure 9.4, the Four Steps of Change Commitment Spectrum is a subset of each of the
Triggers of Change.

The first two steps of the Change Commitment Spectrum frame the change imperative by
answering the questions “why change” and “towards what result.” These answers are
primarily the responsibility of the organization to set forth in a clear and compelling
manner so that the individuals making the changes have the necessary energy and
commitment to move forward with their work. The organization then needs to facilitate
the availability of resources and reward the individuals for engaging in the subsequent
two steps, “assessing needs” based on gap analysis of current capacity and future state,
then “building capability” to meet that capacity through skill development.

The Four Variables of Successful Change

Management Involvement
Low High
High High
Trigger II Trigger IV
Change Commitment Continuum Change Commitment Continuum
Resistance to Change
Step 1 Step 3 Step 1 Step 3
Resource Commitment

Step 2 Step 4 Step 2 Step 4

Trigger I Trigger III

Change Commitment Continuum Change Commitment Continuum

Step 1 Step 3 Step 1 Step 3

Step 2 Step 4 Step 2 Step 4

Low Low
Minor Major Radical

Degree of Change

Figure 9.4: The Four Variables of Successful Change

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Summary

Organizations must approach change by constantly reinventing themselves, continually

making many minor changes so that they are always positioned for the next wave of
change in the environment (e.g., fiscal, political, community health status). This way,
their workforce views change not as strange phenomena to resist but as a concept to
embrace. Change becomes routine if it is always happening. It is normal to change if one
is always doing it. Organizations must constantly ask themselves:
 What needs to change in order for the organization to be a fierce and flexible
force in the marketplace?
 How has the organization changed this week?
 How must the organization change next week?
Organizations have to build a workforce that is willing to take risks and try new ways. It
is a never-ending cycle of change, change, and more change in the flexible organization.

The word Kaizen comes from the Japanese words “kai,” meaning change, and “zen,”
meaning good. Organizations that want to embrace Modular kaizen must be ready to
embrace constant change and continuous improvement towards a defined standard of
excellence that is always increasing.

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 Chapter 10: Daily Work Management: Using Quality Improvement Skills in Daily
Work 1

"If you add a little to a little and do this often enough, soon it will become great."
Hesiod, 8th century BC Greek Poet

The quotation above is the essence of quality improvement (QI) in daily work—many
small, continuous improvements add up over time. QI in daily work is called “daily work
management” (DWM) because it uses the tools and techniques of QI to make daily work
better, more internally and externally customer-focused, and more manageable. By
making daily work more manageable, it helps to reduce stress. DWM is the continuous
improvement of the day-to-day work that is performed. Organizations must train their
workforces at all levels in the tools and techniques of QI to institute organization-wide
DWM. DWM can also be related to Standardized work from the House of Modular
kaizen; Standardized work is consistent performance of a task without waste according to
prescribed methods, focused on human ergonomic movement.

The following steps facilitate application of QI skills to daily work to make

improvements that simplify tasks, focus more attention on the customer, and deliver a
more consistent product or service.

1. How is time spent? Using a Check Sheet, it is useful to review a calendar for a
couple of months to determine in what categories time is spent. Most people find
meetings and e-mails are the major categories, especially at supervisory and
managerial levels. This attribution is fine for a first pass, but to use QI in daily work,
it is important to be more specific. What types of meetings are attended, how are they
related to the job, how much time do they take, are they regular or random meetings?
Answers to these questions help to determine what work is completed on a daily
basis. It is a good idea to continue to monitor where time is spent in order to capture
any changes that take place.

Some QI tools 2 that can help to determine where time is spent are:
 Check or tally sheets;
 Concentration diagrams (pictorial Check Sheets);
 Activity/Time-logs;
 Sampling—pick days to analyze through a random number generator; and
 Pie or Pareto charts to display the data.

1
Parts of this chapter are based on: Duffy G, Moran J, Pierson E. Using QI Skills in Daily Work. The
Quality Management Forum. Winter 2011; 36(4): 6-10.
2
Bialek R, Duffy G, Moran J. The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ
Quality Press, 2009.
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2. What are key processes? Dr. W. Edwards Deming said, “If you can't describe what
you do as a process, you don't know what you're doing.” 3 Once where time is spent is
identified, it will point to the critical processes performed on a regular basis. The next
step is to describe these critical processes with between five and ten high-level
process flow steps. 4 These flow process diagrams of critical processes describe the
daily work completed on a regular basis.
.
A QI tool to help develop a flow process diagram is a SIPOC+CM Form. 5 This form
indicates who suppliers are, where the inputs are generated, the key elements of the
process, where output goes, who the customers of the process are, any constraints on
the process, and what measures are used to indicate how the process is performing.
Another QI tool that can be used is the Flow Chart Summary Matrix 6 which helps
document resources that a process consumes in generating its output.

3. Are customers’ needs and wants identified? For each key process identified and
mapped, the customers’ needs and wants must be described for that process. The first
pass will be the process owners’ understanding of what they think the customers’
needs are. Once this understanding is documented, it should be validated with the
customer for alignment. If the alignment is not confirmed by the customer, the needs
should be corrected and any modifications analyzed to see if the process can deliver
the updated requirements.

Once agreement is reached with customers on needs and wants, the same process
should be performed with suppliers to make sure that they understand needs and
wants, as well.

Some tools of Quality Function Deployment 7 can be used to help with the analysis of
customer wants and needs:
 Process steps impact Customer Needs Matrix
 Kano model
 Understanding/interpreting the Voice of the Customer Table
 Internal/external Customer Needs Matrix

4. Is each step controlled and owned in the processes defined? A key part of
daily QI is that clearly defined process owners understand which parts of the
process they control. Process ownership is important because it establishes the

3
ThinkExist. www.thinkexist.com, Accessed February 19, 2011.
4
Collett C, DeMott J, Moran J. Introduction to critical processes. A GOAL/QPC Application Report No.
92-01A; 1992.
5
Bialek R, Duffy G, Moran J. The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ
Quality Press; 2009.
6
Duffy G, Moran J. Flow Chart Summary Matrix.
http://www.phf.org/resourcestools/Pages/Flow_Chart_Summary_Matrix.aspx, Accessed January 31, 2011.
7
Duffy G, Moran J, Riley W. Quality Function Deployment and Lean Six Sigma Applications in Public
Health. Milwaukee, WI: ASQ Quality Press; 2010.
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 roles and responsibilities for the process and allows those people doing the work
to make improvements. The Control and Influence Matrix 8 is a QI tool used to
check each process step to determine who has control over it and if others need to
be involved in order to make changes.

5. Are measures for the process established? Once the process is defined, it is
important to understand how it is performing. Verifying whether the process is
stable, repeatable, and in control is crucial. Measurement helps to understand how
well the processes are being implemented, goals are being met, customers are
satisfied, and processes are in control. It is important to determine what measures
should be developed as Key Process Indicators (KPI). The following areas are
some major KPIs:
 Effectiveness—Does the process output conform to stated requirements?
Goal: Doing the right things.
 Efficiency—Does the process produce the required output at minimum
resource cost? Goal: Doing the right things well.
 Quality—Does the output meet customer requirements and expectations?
 Timeliness—Does the process produce its output correctly and on time?
 Productivity—How well does the process use its inputs to produce its
output? Goal: Establish the ratio of the amount of output per unit of input.
 Output —How much does the process produce in a given time period?

Depending on the process, the KPI chosen may be a combination of the above or
others. It is desirable to have proactive measures that show what is happening
now in the process rather than reactive measures that show what has happened.
Whatever measures are chosen should give a clear indication of how the process
is operating and when action must be taken.

6. Can the process be monitored and controlled on a daily basis? Once the
process can be measured, it needs to be monitored and controlled daily.
Monitoring and controlling are important activities because these indicate when
the process is out of control and corrective action needs to be taken. Monitoring,
control, and reacting to important processes will be necessary to maintain
performance levels and hold the gains obtained from improvement activities.

Some QI tools useful for monitoring and control are:

 Pareto charts
 Histograms
 Scatter diagrams
 Run charts
 Control charts
 Stem and leaf plots
8
Bialek R, Duffy G, Moran J. The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ
Quality Press; 2009.
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 7. Can processes be improved? Improvement of daily work is the cornerstone of a
quality system. Monitoring and control activities point out where the problem
areas are. Using the Plan-Do-Check-Act (PDCA) cycle helps to analyze and
develop solutions to identified problems. The following QI tools can help
prioritize, analyze, and develop solutions to problems:
 Problem selection grid
 Cause and effect diagrams
 Solution and effect diagrams
 Stop-Start-Continue matrix
 Impact action plots

8. Repeating steps 1–7 on a regular basis checks the process’s performance and
uncovers additional improvement opportunities.

Daily Work Management Case Study 9

Sally the epidemiologist often feels as though her day is not her own; rarely can she get
ahead on her workload. She is responsible for investigating disease outbreaks,
surveillance, planning, and preparedness activities, writing reports, responding to
community requests for data as well as various other tasks. No matter how many To–Do
lists she makes, something always comes up that distracts her from her original priorities.
She would like to manage her daily work better, and she remembers that a colleague
mentioned something about some helpful QI tools that could be applied to her daily
work.

Sally first wants to identify what she does on a typical day and how much time it actually
takes. Her favorite method is to use a random number generator to select one day every
week to analyze. This week Monday was selected, and Sally spent ten minutes filling out
an activity log (Table 10.1). To fill out the Daily Management activity log, she spent
some time reviewing her email to see what she had accomplished on Monday. She went
back through her appointment calendar and e-mails for ten previous Mondays and found
that the majority of her time was spent on communicable disease investigations.

Sally decided to analyze the communicable disease investigations since they took up the
bulk of her time on most days. Her analysis pointed to these investigations as one of the
critical processes she performs on a regular basis. She thought if she mapped out the
process she used to complete an investigation, it might help her figure out where all of
her time is spent. So she found a template for a SIPOC+CM form and filled it out. See
Figure 10.1 for Sally’s SIPOC+CM example.

9
The authors wish to thank Elizabeth Pierson, MPH, CPH, Epidemiologist for Planning and Assessment at
Franklin County Public Health in Columbus, Ohio for developing this case study.

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 Activity Category Amount of time spent
(minutes)
Pertussis, Salmonella Communicable disease 50
investigations
Norovirus Food borne disease 10
investigation
Grant updates Planning and preparedness 25
Communicable disease Monthly meeting 5
reporting system updates
Phone calls and emails from Surveillance 10
hospitals
Table 10.1: Daily Management Activity Log

Constraints:

Limited information from suppliers, no lab Ends with:

Begins with: tests, uncooperative public

Healthy individuals returning to
school or work
Disease report
Process/Activities:

Inputs: Receive disease report, contact provider, Measures:

contact and interview patient(s), call in
Disease report, where patient prescription (if needed), contact labs for tests Percent patients assisted
seen, results from lab tests, info and/or test results, arrange for sample Fewer reported illnesses in
from patient collection, communicate with patient(s) for community
pick ‐up and delivery of test kits and samples,
follow‐up with patient(s) after appropriate
amount of time, follow‐up with providers,
manage data
Suppliers: Outputs:

Hospitals, labs, private physicians, Patient complies with

schools, daycares, health recommendation and prevents
departments, general public further disease spread, remove
patient from sensitive occupation
Customers: until healthy

Hospitals, labs, private physicians, schools,

daycares, general public

Figure 10.1: Communicable Disease Investigation SIPOC+CM

Once Sally understood one of her critical processes, she decided to investigate the
customer needs and wants of this process. To do this, she made a list of potential
customer desires and used a Customer Needs Matrix as shown in Table 10.2. She listed
potential customers and their needs as she understood them. Then she rated the perceived
level of their satisfaction on a scale of 1 to 5 with 1 being low and 5 being satisfied. She
plans to use the last column after she contacts key customers to verify their needs and
current level of satisfaction.

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 Customer Needs Satisfaction Checked
Patients Education, Prevention, 3
Prescriptions
Providers Guidance 3
Table 10.2: Customer Needs Matrix

As Sally reviewed the process flow and other aspects of the process, she realized that she
did not actually have control over all of the pieces of her daily work. Without control, the
daily work had the tendency to manage her. The idea of Daily Management is that Sally
was the driver of the activities, not the other way around. In the packet of information
that her colleague had forwarded to her, Sally found a Control and Influence Matrix
(Table 10.3). She sensed that by evaluating her level of control, she might refine the
process more effectively and manage her time in more appropriate ways.

Control No control
Knowledge

Data management Prescribing medication

[Do it] [Influence]

knowledge

Receive disease reports from Patients don’t return phone calls

providers
[Get help] [Stay away]
No

Table 10.3: Control and Influence Matrix

What she found was that she really had control only over data management. She had
some influence when she contacted the provider and the patient or the lab and limited or
no control over whether individuals returned her calls or picked up kits for testing.

Having control over a process is not the only information Sally needs to manage a
process; she needs to know a few more specifics. For instance, she needs to review the
“how” of the process; measuring indicators of the process can help to ensure that she is
getting the results that she wants.

Of several key process indicators, Sally chose to assess the timeliness and quality of her
Daily Management tasks, particularly as they relate to managing the data. In this instance,
that would mean she would need to review and/or input data into the disease reporting
system within a short timeframe. Sally decided to monitor the amount of time that had
elapsed between notification of a disease and the first phone call to the patient. She also
wanted to add a question about satisfaction to the end of each patient phone call. Based
on her reviews with key customers, she determined that a goal of 30 minutes would be
appropriate for the review of data and a phone call to the patient.
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Sally decided to set up a Run Chart to track performance against a goal appropriate for
reviewing and/or inputting data into the disease reporting system. She set up a tracking
log to record each time she reviewed or entered data into the disease reporting system and
the amount of time that elapsed between notification and action. The Run Chart for the
last 20 entries is shown in Figure 10.2. These measurements are the first that Sally took;
she made a run chart that gave her a total picture of the outcome of her new Daily
Management activities. She needed to get an initial understanding of her performance on
a real-time basis to see if she was close to the targets that she had set for herself. The Run
Chart showed that of the last 20 entries, the median amount of time that had elapsed
between notification of a disease and the first phone call to the patient was more than her
personal target of 30 minutes. A simple look at the Run Chart indicates that Sally has
more work to do in managing this part of her daily work. At this point she does not know
whether the 30 minute target is too optimistic or whether other improvements can be
made to the routine that she has for receiving the notification and making first contact
with the patient.

Monitoring a run chart is an important activity since it indicates when the process is
trending upward or downward or when the average shifts. Sally’s use of simple QI tools
has clearly indicated that she is not there yet.

80
Measurement (in minutes)

70
60
50
Median line
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Time (in days)

Figure 10.2: Run Chart

When reviewing the Run Chart, Sally realized that some inconsistencies were evident in
the amount of time it takes to complete the first steps of the investigation—receiving the
data, reviewing it, entering it into the data management system, and calling the patient.
As Sally had realized earlier, she had control over the data management piece, so she
decided that it was the reviewing and inputting into the system that needed improvement.
Sally put together a simple Cause-and-Effect Diagram to investigate further, which is
shown in Figure 10.3.

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Modular kaizen: Dealing with Disruptions Chapter 10
Completing the Fishbone Diagram helped Sally clarify some of the issues that could be
directly addressed in the investigation process. She was able to select one of the
categories identified and make changes accordingly. Sally also continued to monitor the
timing and efficiency of processes so that she could systematically review the data and
continue her improvement activities.

Figure 10.3: Fishbone Diagram (cause and effect)

Conclusion

Henry Ford is quoted as saying, “Quality means doing it right when no one is looking.”
Daily Work Management (DWM), when done well, is practiced day in and day out at all
levels of the organization. DWM may not be apparent except for some up-to-date
measurement charts on a wall or some employees meeting to solve a common problem
using QI tools. It may show up as employees making a presentation using QI tools and
techniques or a conference room containing a Fishbone Diagram on a flip chart from a
previous meeting.

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Some signs to notice which indicate that daily management is not yet a reality in an
organization are: 10
 The quality of a process’s output is different from shift-to-shift, location-to-
location, person-to-person. This inconsistency relates to a lack of standardized
methods, poor training, or a lack of accurate metrics.
 The same problems continually recur after continually being fixed.
 Work processes were never planned out and instead evolved over time by
different people doing the job.
 Different areas doing the same work have different forms, collect different data,
and use different technology systems.
 Interacting processes have different goals and objectives. A smooth hand-off does
not occur, and items are often lost or delayed.
 A constant crisis mode of operation is in place.
 Employees are blamed for problems that occur.
 Customers complain about a lack of service or long waits.
 Poor documentation of changes made to the process occurs. Often changes are not
 communicated clearly to those involved.
 When veteran employees take a vacation or leave, problems arise because no one
else knows how tasks are normally accomplished. They were never documented.

For Daily Work Management to be effective, everyone must understand how a process
works, how the process interacts with other processes in the organization, and how it
contributes to the strategic direction of the organization. Everyone must feel ownership of
the process and its output. Measurement must be a way of life. Measurement is a vehicle
for improvement, not punishment. Everyone must have a customer/supplier orientation in
which wants and needs are communicated and understood. Equally important is that an
evolving culture in which the status quo is constantly being challenged exists. Sally
began her journey using some very basic tools of quality to help organize her daily
management tasks that allow her to measure real-time performance against her own
personal targets. Individual performance tracking does not have to be complex. daily
management is a personal target and a personal success story. The more that individuals
use the skills and tools learned as team members in daily activities, the sooner a culture
of QI will be experienced throughout the entire organization.

10
The ROI Alliance, LLC. www.roi-ally.com. Updated 2010. Accessed February 19, 2011.
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Modular kaizen: Dealing with Disruptions
 Appendix A: Dr. W. Edwards Deming

W. Edwards Deming is referred to by many quality professionals as the primary quality

“guru” of the 20th century. Although this reference is arguable, the authors refer to
Dr. Deming as a way to orient the reader to the early designers of the current quality
movement.

William Edwards Deming was born on October 14, 1900 in Sioux City, Iowa. His family
moved to several other locations before settling in Powell, Wyoming. Dr. Deming
attended the University of Wyoming, earning a bachelor’s degree in engineering in 1921.
He went on to receive a master’s degree in mathematics and physics from the University
of Colorado in 1925. He earned a doctorate in physics from Yale University in 1928.
During the summers of 1925 and 1926, he worked for the Western Electric Company
Hawthorne Plant in Chicago. It was at Hawthorne that he met Walter A. Shewhart and
became interested in Shewhart’s work to standardize the production of telephone
equipment. After receiving his PhD, Deming went to work for the United States
government, applying Shewhart’s concepts to his work at the National Bureau of the
Census. Transforming routine clerical operations into statistical process control in
preparation for the 1940 population census led to six-fold productivity improvements in
some processes. As a result, Deming started to run statistical courses to explain his and
Shewart’s methods to engineers and designers in the United States and Canada.

In 1938, Deming published Statistical Adjustment of Data and taught courses in the use
of his statistical methods. The beneficial effects of Deming’s programs such as reductions
in scrap and rework were seen during World War II. However, use of his techniques was
generally abandoned after the war as the emphasis turned more to producing quantities of
consumer goods to alleviate the shortages experienced during wartime.

After the war Deming was invited to Japan as an adviser to the Japanese census. He
became involved with the Union of Japanese Scientists and Engineers (JUSE) after its
formation in 1946. JUSE invited him to lecture to the Japanese on statistical methods. In
the early 1950’s, he lectured to engineers and senior managers, including in his lectures
principles now regarded as part of modern quality principles. In 1956, Deming was
awarded the Shewhart medal by the American Society for Quality. Four years later,
Deming’s teachings were widely known in Japan, and the Emperor of Japan awarded him
the Second Order of the Sacred Treasure.

In the late 1970’s, Deming started to work with major American organizations. However,
his work was still relatively unknown in the United States until June 1980 when NBC
aired a documentary called “If Japan Can, Why Can’t We?” Following this exposure, he
became well- known and highly regarded in the quality community.

Deming’s teachings reflected his statistical background by encouraging managers to

focus on variability and understand the difference between special causes and common
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Modular kaizen: Dealing with Disruptions Appendix A
causes. However, his writings, teachings, and work also extended beyond statistical
methods; he encouraged organizations to adopt a systematic approach to problem solving,
which later became known as the Deming cycle or PDCA (Plan, Do, Check, Act). He
also pushed senior managers to become actively involved in their companies’ quality
improvement programs. Work completed by Deming and his followers in the United
States and elsewhere has attempted to make major changes in the style of Western
management. Deming constantly improved and refined his ideas and is considered by
many to be the father of the modern quality revolution.

Dr. Deming taught that management should have a full understanding of his philosophies
in order to achieve sustainable progress in an organization. In his landmark 1986 book
Out of the Crisis, Dr. Deming delineated the revolutionary management philosophy for
establishing quality, productivity, and competitive position. In the book he discusses
management’s failures in future planning, mainly in the prediction of problems. These
shortcomings create a waste of resources which in turn increase costs and ultimately
impact the prices to customers. When customers do not accept paying for such waste,
they go elsewhere, resulting in loss of market for the supplier.

In the introduction to Out of the Crisis, Dr. Deming talks about the need for an entirely
new structure from the foundation upward to achieve the needed transformation and
replace the typical American reconstruction or revision approach. Dr. Deming suggests
the new structure in his renowned “14 Points of Management.” The 14 points include
creating a constant purpose for the organization, eliminating reliance on inspection,
constant improvement in systems, increased training, and instituting leadership.

In Out of the Crisis Dr. Deming also discusses his seven “Deadly Diseases” that include a
lack of constancy of purpose, focus on short-term profits, management that is too mobile,
and excessive medical and legal costs. In 1987, the year after publication of Out of the
Crisis, Dr. Deming was awarded the National Medal of Technology in America.

In his final book, The New Economics for Industry, Government, Education, Dr. Deming
outlined his System of Profound Knowledge. This knowledge is needed for
transformation from the present style of management to one of optimization. Deming’s
system of profound knowledge includes management’s need to understand systems,
knowledge of statistical theory and variation, planning based on past experience, and
understanding of psychology.

Dr. Deming died in 1993 at the age of 93.

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 Appendix B: Additional References

Books:

Beecroft G, Duffy G, Moran J. The Executive Guide to Improvement and Change.

Milwaukee, WI: American Society for Quality (ASQ) Quality Press, 2003.

Bialek R, Duffy G, Moran J. The Public Health Quality Improvement Handbook.

Milwaukee, WI: ASQ Quality Press; 2009.

Duffy G, Moran J. Applications and Tools for Creating and Sustaining Healthy Teams.
Published on www.phf.org. March 2011.

Duffy G, Moran J, Riley W. Quality Function Deployment and Lean Six Sigma:
Applications in Public Health. Milwaukee, WI: ASQ Quality Press; 2010.

Duffy G, Moran J. Executive Focus: Focusing your Life and Career. Milwaukee, WI:
ASQ Quality Press; 2008.

Articles:

Armbruster S, Kane T, Moran J. Developing a Health Department Quality Improvement Plan.

PHF Website. December 2010.
http://www.phf.org/resourcestools/Documents/Developing_a_Quality_Improvement_Plan.pdf

Beaty S, Moran J. Mid-State Health Center Quality Improvement Case Study. New England
Rural Health Roundtable Newsletter. September 2010.
http://www.phf.org/resourcestools/Pages/The_Mid_State_Health_Center_Quality_Improvement
_Case_Study.aspx

Beitsch L, Duffy G, Moran J. Ready, AIM, Problem Solve. Quality Texas Foundation
Update. October 2009.
http://www.phf.org/resourcestools/Pages/Ready_AIM_Problem_Solve.aspx

Bialek R, Duffy G, Moran J. SIPOC + CM Diagram. Healthcare Update: Quality Tools

and Applications. American Society for Quality, January 13, 2009.
http://www.asq.org/healthcare-use/why-quality/sipoc.html

Bialek R, Duffy G, Moran J. On-the-Job Tool: Spaghetti Diagram. ASQ Weekly. October 13,
2010.

Bialek R, Duffy G, Moran J. Spaghetti Diagram. Healthcare Update: Quality Tools and
Applications. March 9, 2010.
http://asq.org/learn-about-quality/process-analysis-tools/overview/spaghetti-diagram.html
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Duffy G, Henry B, Moran, J, Parsons H, Riley W. Realizing Transformational Change
through Quality Improvement in Public Health. Journal of Public Health Management
and Practice. 2010: 16:(1): 72-78.

Duffy G, McCoy K, Moran J, Riley W. The Continuum of Quality Improvement in

Public Health. The Quality Management Forum. 2010:35:(4).

Duffy G, Moran J. A Complete Quality System Requires A Complete Leader. Quality Texas
Foundation Update. December 2010.
http://www.texas-quality.org/SiteImages/125/Newsletter/December%20Newsletter%202010.pdf.

Duffy G, Moran J. Flow Chart Summary Matrix. PHF E-News. March 2, 2010.
http://www.phf.org/resourcestools/Pages/Flow_Chart_Summary_Matrix.aspx

Duffy G, Moran J. Force and Effect Chart Guides Teams through Addressing Barriers. Six
Sigma IQ. August 2010.
http://www.processexcellencenetwork.com/methodologies-statistical-analysis-and-
tools/articles/force-and-effect-chart-guides-team-through-address/

Duffy G, Moran J. Modified Approach: Modular kaizen. Six Sigma Forum Magazine.
2010: 9:(4).

Duffy G, Moran J. Starting and Sustaining a Complete Quality System. Quality Texas
Foundation Update. August 2010.
http://www.phf.org/resourcestools/Pages/Starting_and_Sustaining_a_Complete_Quality_
System.aspx

Duffy G, Moran J. Team Chartering. Quality Texas Foundation Update. April 2010.
http://www.texas-quality.org/SiteImages/125/Newsletter/April%202010%20Newsletter.pdf

Duffy G, Moran J, Riley W. Rapid Cycle PDCA. Quality Texas Foundation Update.
August 2009.
http://www.phf.org/resourcestools/Documents/2009.8_Article_Quality_Texas_Foundatio
n_Newsletter_Rapid%20Cycle%20PDCA.pdf

Duffy G, Moran J, Riley W. TAPP into the PDCA Cycle to Make Improvements in
Public Health. Quality Texas Foundation Update. June 2009.
http://www.texas-quality.org/SiteImages/125/Newsletter/June%202009%20%20Newsletter.pdf

Duffy G, Moran J, Riley W. TAPP into the PDCA Cycle to Make Improvements in
Public Health. ASQ Healthcare Update Newsletter. May 2009.
http://www.phf.org/resourcestools/Documents/TAPP_into_the_PDCA_Cycle.pdf

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Gorenflo G, Moran J. The ABC’s of PDCA. PHF Website. April 2010.
http://www.phf.org/resourcestools/Pages/The_ABCs_of_PDCA.aspx

Katkowsky S, Kent L, Divine S, Hunter J, Bialek R, Beitsch L, Moran J. Using QI Tools

to Make a Difference in H1N1 Flu Immunization Clinics: A Local Health Department's
Experience. Pandemic Flu Week in Review. January 8, 2010.
http://healthyamericans.org/assets/files/NKYClinicFINAL.pdf

Moran J. Top “10” Problems Encountered by Quality Improvement Teams. PHF Pulse
Blog. 2010.
http://www.phf.org/phfpulse/Pages/Top_Problems_Encountered_By_QI_Teams.aspx

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 Appendix C: Templates and Examples

Many of the figures and tables that appear in this book can be adapted for use in new
settings and circumstances. With that in mind, this Appendix provides templates and
examples using these tools.

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 Rapid Cycle PDCA/PDSA Pre-Planning Check Sheet 1

C
The following are questions that should help guide you when starting a Quality
Improvement Project using Rapid Cycle PDCA/PDSA. This checklist helps guide you
through the Rapid Cycle planning that needs to take place to ensure a successful
improvement project.

The check sheet is constructed to indicate what has been completed (√) and what needs to
be done (TBD and Date) and the expected completion date.

Step Rapid Cycle Questions TBD/ 

Date
PLAN What is the focus/AIM of this improvement project?
What are the improvement goals?
Who is impacted?
What is impacted?
When is it impacted?
Where is it impacted?
Why is it impacted?
How is it impacted?
Who is the customer?
Who is the supplier?
What are the constraints?
What is the rapid cycle time line?
Who should be on the improvement team?

1
©2009 G. Duffy, J. Moran, and W. Riley
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Step Rapid Cycle Questions TBD/ 
Date
 Who are the right people?
 What training does the improvement team require?
 Who will deliver the required training?
 When will the required training be delivered
What do we predict will happen?
Measurement(s) defined /developed to show current performance and
track future improvements?
Action plans developed to detail what will be done by who and when?
Communication plan developed to inform needed parties of potential
changes, timing, and status?
What additional information will we need to take action?
Other Plan questions unique to your improvement project?
DO Improvement plan developed?
When will the improvement plan be implemented?
When will the pilot test be carried out?
What did we observe from the pilot test?
Did we get sponsors approval and their support if implementing means
going outside our personal area of responsibility?
Did we document the implemented changes so the process can be
duplicated and standardized?
Check/ Did the pilot test results agree with the predictions that we made earlier?
Study  If not, why?
What new knowledge was gained through this cycle?
How will we use this new knowledge to make additional improvements?
Are we continually checking the results as the process is initiated and
after it is in place to determine if the changes are meeting requirements?
Did we determine if the measurements used to determine success is
adequate?
Did we remember to automate data gathering if at all possible?
ACT Did we go back to ‘Plan’ if the process still is not meeting requirements
investigate additional process improvement opportunities?
Did we make minor adjustments and document them?
Did we standardize the change and initiate the SDCA Cycle initiated?
If the process changes are meeting requirements have we set up a way
to continue to monitor after we standardize them?

Add other questions that are applicable to your particular improvement project.

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 RESPONSE TEAM CHARTER

2. Team Name: 3. Version: 4. Subject:

5. Problem / Opportunity Statement:

6. Team Sponsor: 7. Team Leader:

8. Team Members: Area of Expertise:

1.
2.
3.
4.
5.
9. Process Improvement aim (Mission):

10. Scope (Boundaries):

11. Customers (primary and other): Customer Needs Addressed:

12. Objectives:



13. Success Metrics (Measures):

14. Considerations (Assumptions / Constraints / Obstacles / Risks):

.

15. Available Resources: 16. Additional Resources Required:

17. Key Milestones: Date:

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18. Communication Plan (Who, How, and When):

19. Key Stakeholders: Area of Concern (as it relates to the

Charter):

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 Appendix D: Modular kaizen Author Biographies

Ron Bialek, MPP, CQIA is President and CEO of the Public Health Foundation (PHF).
Under his leadership over the past 14 years, PHF has focused its efforts on developing
and implementing innovative strategies for improving performance of public health
agencies and systems. Initiatives include developing performance management and
quality improvement tools and training for public health professionals; developing the
consensus set of Core Competencies for Public Health Professionals through the Council
on Linkages Between Academia and Public Health Practice; creating the Nation’s most
comprehensive public health learning management system – TRAIN – linking together
23 states, the U.S. Medical Reserve Corps, and the Centers for Disease Control and
Prevention’s Division of Global Migration and Quarantine; and developing consumer-
oriented county health profiles – the Community Health Status Indicators initiative – for
all counties in the U.S. Mr. Bialek recently served as one of the editors for the new
Public Health Quality Improvement Handbook.

Grace L. Duffy, MBA, CMQ/OE, CQA, CQIA, CLSSMBB provides services in

organizational and process improvement, leadership, quality, customer service, and
teamwork by designing and implementing effective systems for business and
management success. Her clients include: the Library of Congress; the Charleston,
South Carolina Veterans Administration Medical Center; the Food and Drug
Administration Center for Food Safety and Nutrition; Florida Department of Children
and Families; and the U.S. Department of Energy Strategic Petroleum Reserve. During
her 20 years with IBM, Ms. Duffy held positions in technical design, services,
management and process improvement. She helped design and deliver IBM’s Executive
Quality training in the late 1980s. Ms. Duffy worked with Trident Technical College in
Charleston, South Carolina for ten years as department head for Business, curriculum
owner and instructor for Trident’s Quality and Corporate management programs, and as a
Dean for management and performance consulting to private industry. Ms. Duffy holds a
Masters in Business Administration from Georgia State University and a Bachelor’s in
Archaeology and Anthropology from Brigham Young University. Ms. Duffy is an ASQ
Certified Manager of Quality-Organizational Excellence, Certified Quality Improvement
Associate, Certified Quality Auditor, Certified Lean Six Sigma Master Black Belt, and
Manager of Process Improvement. She is a Senior Research Fellow with Purdue
University and a Lean Six Sigma mentor to the University of Central Florida Graduate
Engineering programs. In addition, she is a co-author of The Public Health Quality
Improvement Handbook, The Executive Guide to Improvement and Change, and
Executive Focus: Your Life and Career.

John (Jack) W. Moran, PhD, MBA, CQM, CMC, CQIA is a Senior Quality Advisor
with the Public Health Foundation (PHF). He brings to PHF over 30 years of quality
improvement expertise in developing quality improvement tools and training programs,
implementing and evaluating quality improvement programs, and writing articles and
books on quality improvement methods, including The Public Health Quality
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Improvement Handbook and Executive Focus: Focusing Your Life and Career. In his
role with PHF, he provides consultation, training, and technical assistance to the public
health field and has conducted several visits to local and state health departments
including Minnesota, New Hampshire, New Jersey, Oklahoma, and Pennsylvania. Dr.
Moran is a retired Senior Vice-President of Information Systems, Administrative and
Diagnostic Services at New England Baptist Hospital. He has also served as Chief
Operating Officer of Changing Healthcare, Incorporated, specializing in management
consulting and educational support to healthcare organizations. For 21 years, Dr. Moran
was employed at Polaroid Corporation where he worked in various senior management
roles in manufacturing, engineering, and quality. His last position was as the Director of
Worldwide Quality and Systems. For 20 years, Dr. Moran was an Adjunct Professor in
the School of Engineering at the University of Massachusetts at Lowell. Dr. Moran has
been active in the American Society of Quality (ASQ) as a Fellow of the Society and as
past Exam Chair of the Certified Quality Manager’s Exam. Dr. Moran is an ASQ
Certified Quality Manager (CQM) and a Certified Management Consultant (CMC) by the
Institute of Management Consultants. Dr. Moran is a member of the Malcolm Baldrige
Board of Examiners. He holds a BS, MBA, MS, and PhD in education from Walden
University.

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 Index

A
Accelerate change, 98
Accountable Government Initiative, 2
Association of Disruption to Area of Concern Form, 59-61, 123

B
Big “Q,” 32, 33

C
Capacity measures, 71
Change agent dimensions, 93
Change commitment spectrum, 96-97
Change management, 13, 15, 17, 43, 55, 91-100
Characteristics of an effective team, 51
Check/act repeating improvement cycle, 28
Check sheet, 58, 79-80
Checklist, 81
Circle of influence, 48
Common cause variation, 78-79
Control and influence matrix, 103, 106
Control chart, 73, 79, 85-88, 103
Customer needs and wants, 105

D
Daily work management, v, 21, 43, 46, 50, 58, 101, 108
Disruption and Impact Diagram, 65, 120
Disruption and Impact Matrix, 34, 35, 47, 48, 52, 59-62
Disruption Form, 65-66, 122
Disruption identification, 18, 45, 58, 64
Dr. W. Edwards Deming, iii, 103, 111

E
Eight (or 8) lean wastes, iv, 19-20
Effective team building, 50
Error proofing, 19, 80

F
Fast transition, 21, 58, 64, 89
Fishbone diagram, 108
Five S (or 5S), 16, 17-18

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Flow chart, 39-41, 102
Force & Effect + c a Chart, 19, 50, 63, 65, 124

G
Gap analysis, 45, 98-99

H
House of lean, 15
House of modular kaizen, iii, 8, 13-15, 17, 21, 58, 89, 101, 125

I
Immunization checklist, 81

K
Kaizen, 24, 100
Kaizen Blitz, v, 19, 24, 25, 37
Key performance indicators, 1, 7, 10, 45-46, 60
Key process indicators, 71, 103, 106
Key processes, 102

L
Lean process, 36
Lean wastes, iv, 26
Limited information collection principle, iv, 26, 69
Little “q,” 32-33

M
Mistake proofing, 89
Modular kaizen definition, 23
Modular kaizen example, 27
Modular kaizen flow, v, 26, 46, 58

O
Outcome measure, 74-75
Out-of-control rules, 86

P
Paynter Chart, 84-85
PDCA or PDSA cycle, iii, iv, vi, 14, 21, 27, 29, 45-46, 55-58, 66, 77-78, 104, 112
Performance management components, 6-8
Performance management framework, 10
Performance management measures, 3
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Poka-Yoke (or Poka-Yoka), 89
Process control, 16, 19, 21, 58, 64, 67, 79, 111
Process map, 3, 15, 17, 33, 39-42, 66-67
Process measure, 72-73, 103
Project management, 19, 58-59, 64
Pull technology (Kanban), 17, 21

Q
Quality at source, 16, 19, 58

R
Rapid Cycle PDCA, 55-58, 118
Response process map, 67
Run charts, 73, 79, 82, 84, 88, 103, 107

S
Shigeo Shingo, 89
SIPOC+CM, 37-39, 64, 102, 104-105, 128
Signposts, 98
Special cause variation, 78-79, 82
System view, 31

T
Team Charter, 129
Teams, iv, 16, 19, 45-53, 59
Trigger of change, 94-96
Tri-metric matrix, 67-72, 74-75, 131
Turning Point Model, 3-8

V
Value (stream) map, 4, 5, 14-17, 39, 41
Variation, 45-46, 72-73, 78-79, 82, 84-87

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