In the last session, we discussed process maps and pointed out that these maps are generally used in conjunction with rapid improvement events or, as many TPS experts call them, Kaizens. In this session, we would describe this important approach for improving quality and efficiency of patient care. Rapid improvement events are highly efficient in transforming social events. They usually involve six to 10 people, and as the name implies, they are rapid, taking four to five days. These events are used to identify and remove waste by creating a new, improved process. The improvement is immediately implemented. No further approval is required. And because there is no potential veto by higher-ups, these events respect and empower employees to solve the daily problems found on the front lines. Before beginning a rapid improvement event, there need to be two to three months of advance work, usually performed by the facilitator. Many recommend using an A3 form to guide all of the work involved in a rapid improvement event. Before the event begins, the facilitator should fill out the reason for the action, the current conditions, and the target state. The facilitator should also have identified clear and measurable metrics. The facilitator also must be the process owner, that is, someone directly involved in the process, someone who takes responsibility not only for helping to implement the changes, but to also ensure that the changes are sustained. The RIE team consists of the facilitator, who should be an experienced Lean practitioner who is familiar with all of the improvement tools; the process owner, who is responsible for implementing improvement and for sustaining. There should only be one process owner to assure there is not diffusion of responsibility. The team leader conducts the RIE and, like the facilitator, should be experienced in Lean. He or she keeps the team focused. Other members should include the frontline staff involved in the process or upstream or downstream of the process. It is important to include physicians when trying to improve any clinical process. Because of the full-time commitment for four to five days, their time must be paid for. The physicians on the team can present the team plan and outcomes at physician conferences, increasing the likelihood of initial success and sustainability. In some cases, an internal expert consultant may be required. However, the expert can usually be used briefly to assure that the team is guided in the proper direction and is provided with a key understanding of the process. Effective RIEs usually follow a set schedule. On day one, they undergo a team launch, as described in "Fixing Healthcare Delivery 1.0." It is important that behavior norms be discussed. Most important, respectful communication must be the rule, and team members should be communicating using first name to reduce hierarchy. All team members should be encouraged to share their ideas and the facilitator assure that all voices are heard. Following the team launch, the facilitator and process owner should provide a one-hour overview, reviewing the background and describing the current state. The overview should be followed by creation of the current state process map. And using this map, the team should begin problem solving, root cause analysis, and begin to envision the target state. Day two is usually the hardest day, often called Terrible Tuesday. On this day, the RCA should be completed and the future or target state fully described. In addition, the team should create a process map of the target state. This should be followed by a gap analysis. What are the differences between the current state and the future states? This requires the identification of non-value added processes. Following the gap analysis, a summary of the RCA, current state, target state, and the gap analysis is presented to the administrative sponsor. This assures this administrator fully understands what the team is trying to accomplish and why, because at the end of the RIE, this administrator must approve implementation of the improvement plan. Day three is the day when rapid improvement experiments are performed to improve flow and efficiency. Because the frontline personnel have a deep understanding of these work processes, they are the ones who have the expertise to create the standardized work for the new process. Once new standardized work has been designed, there must be agreement on the verification metrics that would determine whether these changes in procedure represent a true improvement and correct the problems identified during the current state process mapping. On day three, the teams also should create a production board, a visual control, to monitor progress toward achieving the target state. On day four, the team adjusts and fine tunes the process. Then, they create a training program and training schedule. On day four, they also report to the administrative sponsor and answer any questions. On the final day, the team reports the final plan to the administration and to other interested stakeholders. Following this final report, the team celebrates their achievements. It is important to document this journey by completing the A3 form because this document provides a permanent record of the rationale, strategies, and expected future state as well as the metrics to determine if this future state has been achieved. Most important, A3 form summarizes the team's improvement plans and serves as the blueprint for implementing and sustaining each process improvement. This is the A3 form that should be filled out for each RIE. This template is available for free on the Fixing HealthCare Delivery site. Process mapping combined with rapid improvement events provide a systematic approach to creating standardized work. The RIE empowers those working on the frontlines and models a culture of safety by creating a flat hierarchy. These methods are highly effective for creating rapid and effective improvement plans. And because they are designed to harness the expertise of those working on the frontlines, they have been proven over and over again to be capable of achieving sustainable improvement. These tools are the workhorse of Lean. Thank you.
