Clearly the criteria, discipline, and focus that underlie the Baldrige process have been key contributors to our daily improvements. The feedback we received … has been instrumental in providing a clear road map for the journey.—Michael Murphy, CEO, 2007 Baldrige Award recipient, Sharp HealthCareIncremental change is how a culture of continuous improvement creates a pattern of success. In the Discussion for Week 4, you examined an organization’s actions in relation to criteria of high reliability and recommended steps for improvement. This week, you will revisit your recommendations.Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by selecting the “Post to Discussion” link and then select “Create Thread” to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before selecting Submit!To prepare for this Discussion:Read this week’s articles on the standards for high reliability, then review the Week 4 Discussion. Draw comparisons between your organization and others, and examine any feedback provided by your peers.Post a cohesive response to the following:With the feedback and this week’s readings in mind, reexamine the steps for improvement of high reliability which you suggested for your organization. Would you change your recommendations in light of what you have learned in this course? Could your recommended steps be expanded or refined?Support your response by identifying and explaining key points and/or examples presented in the Learning Resources.
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Vinas, Tonya
Lean management case study series
Pediatric Hospital in Tough Market Pegs Growth to Lean Process Improvement
By Tonya Vinas
Akron Children’s Hospital (ACH), a regional pediatric care system headquartered in
Northeast Ohio, could be compared with David, the young lad who courageously brings
down a giant in a classic Old Testament tale.
In this story, though, David battles two giants.
Akron is about 35 miles south of Cleveland, where two nationally ranked pediatric
hospitals draw families from around the world who need specialized care for their
children’s complex medical problems. Parents are attracted to the hospitals’
international reputations for being among the best: The Cleveland Clinic’s Children’s
Hospital and University Hospital’s Rainbow Babies and Children’s Hospital are known
for breakthrough research, life-saving surgeries and treatments, and other medical
innovations. They also aggressively recruit gifted doctors, leading scientists, and other
medical experts at the top of their professions.
But ACH, which certainly has a stellar regional reputation, is taking a unique weapon
into the field as it battles for a bigger slice of the state’s pediatric care market. While the
two Cleveland hospitals have continuous-improvement programs, neither has made
continuous improvement a strategic imperative across its entire enterprise as ACH has.
The hospital’s Center for Operations Excellence (COE) is the engine that propels all
employees and functions toward the growth goals set by executives and board
members in hoshin kanri (strategy deployment) planning. Leaders are confident that the
COE and its lean six sigma-focused training and project leadership give ACH enough
competitive advantage to succeed, even in the same geographic market as two
healthcare giants.
ACH’s expansion plan includes increasing the number of patients served both
geographically and within certain sub-specialties; becoming the No. 1 choice for parents
and referring physicians through quality achievements and availability of services;
improving on infrastructure, quality, and clinical programs; and becoming the primary
site for pediatric medical research in Northeast Ohio.
Already, the three-year-old COE has been widely embraced and highly effective.
Projects have saved ACH millions of dollars, increased utilization of expensive assets,
and reduced wait times and processing for patients and their families. The short-term
gains are important, said Doug Dulin, the COE’s senior director, but the learning and
commitment that each project builds internally are more crucial.
“What it comes down to is that we have to create a competitive advantage,” said Dulin,
who learned the Toyota Production System at Aoyama Seisakusho, a Tier One supplier
to Toyota Motor Manufacturing. “So how can we transfer what we’ve already done into
every segment of the hospital? That’s how the Center for Operations Excellence fits in.
This is a long-term journey.”
Akron Children’s Hospital at a Glance

Largest pediatric healthcare system in northeast Ohio.
Operating two freestanding pediatric hospitals and offering services at nearly 80
Pediatric specialties draw half a million patients annually, including children, teens,
and adults from all 50 states and around the world.
Level-Loading Schedule Improves Quality, Access, and Revenues
In addition to the challenge of having two highly regarded competitors in the market,
ACH must do much more with much less. It doesn’t receive the numerous large grants
and donations that the others do; and since all of the hospital’s patients are children, it
can’t rely on Medicare reimbursements. Also, both the Clinic and UH are closely aligned
with Case Western University Medical School in Cleveland, and so have access to more
intellectual property, research programs, emerging technologies, and other assets than
ACH has.
The hospital system’s smaller and less complex operation, however, seems to have
been an advantage for quickly absorbing the lean culture. Evidence of how open all
levels of the organization have been to lean is the speed with which a large number of
employees — including doctors — have come together to identify problems, find the
root causes, and then agree on countermeasures.
“There’s something about the culture at Children’s that allowed this to be very effective,
very quickly,” said Board Member Bill Hopkins. “They were just primed for this. It speaks
volumes about the commitment from everybody — the leadership, staff doctors,
For example, MRI scheduling was one of the first areas the COE addressed because it
had potential for significant and fast improvement, and because the hospital had not
been able to effectively utilize a second MRI machine it had purchased. The most
apparent barrier was a bottleneck in scheduling.
A kaizen event revealed that variability was the root cause:Children are more prone to
move during exams when they need to be still, a reality that extends their appointment
times because readings frequently need to be delayed or redone. On any given day,
more than half of the hospital’s patients are five-years-old or younger, and so are
particularly prone to moving during exams. Some children need to be sedated to keep
them still. This causes more variability because a doctor needs to administer the
sedation, and doctors’ schedules routinely change without notice because of
emergencies and other unexpected events. The result was a backlog of patients with
appointments, and long wait times for those needing new appointments.
The two-day kaizen — which included radiologists, radiology technologists, schedulers,
nurses, and the employees who handle insurance authorization and registration —
produced multiple solutions:

Modifying the master schedule.
Streamlining the insurance authorization Process.
Implementing standardized work instructions.
As is often the case with a level-loading solution, modifying the master schedule
seemed counterintuitive, but it worked. More time was scheduled for each exam, a
change that made it easier for the end-to-end Process to absorb variability and remain
level (on schedule). This eliminated the bottlenecks that were causing the long wait
times for exams and results. In cycle-time terms, the “appointment-to-results” cycle
shrunk drastically as the department got its scheduling Process under control. As a
result, more capacity opened, and this allowed an increase in throughput
(appointments) without adding resources.
“Before the kaizen, the hospital was doing about 86 MRIs per week. Now, on average,
we are doing 112,” Dulin said. “That is good news for our patients and the physicians
who are waiting on the results of those tests. Instead of waiting 25 days for an
uncomplicated exam, families can now schedule same-day appointments.” (See chart:
Outpatient MRI Appointment Wait Times.)
The project significantly improved the hospital’s bottom line, with $1.2 million in
additional revenue attributed to the better MRI scheduling.
It also earned ACH an honorary mention award at the International Quality and
Productivity Center’s Lean six sigma & Process Improvement Summit in January, 2011.
The award was in the category of “Best Process Improvement Project Under 90 Days,”
with Akron Children’s competing against five other international companies and
organizations that were selected as finalists.
Outpatient MRI Appointment Wait Times: A cross-functional kaizen team at Akron
Children’s Hospital dramatically cut the MRI schedule backlog by applying lean
Surgery: Greater Capacity, Higher Quality without $3.5 Million Expansion
Perhaps the most striking example of how lean processes will feed ACH’s efficient
growth is the avoidance of spending $3.5 million to enlarge the sterile processing area
within the surgery department. According to Mark Watson, president of the ACH
Regional Network, surgeons were performing 12,000 operations a year, and the number
of cases was increasing. (They performed 14,000 in 2010.) Sterilization technicians had
a hard time keeping up, but expanding space and staff would have been a problem.
“Our surgery area is landlocked,” explained Watson, who first introduced the idea of
lean Process improvement to the hospital. “In order to give sterile processing more, I
would have to take away from someone else. So we started really looking at what was
going on in the operating room, and we started with our flash-sterilization rate.”
The team decided this was the most urgent need — a flash sterilization rate of 10
percent was not acceptable, Watson said. (Flash sterilization is the immediate and
unscheduled sterilization of instruments that have been dropped or otherwise
contaminated during the surgery processes. It is a quality problem that creates
variability and waste.) They scheduled a kaizen focused on reducing flash sterilization.
The resulting improvements not only reduced flash sterilization to 2 percent, but also
opened all the capacity needed to add an additional 4,000 surgeries a year.
“It was amazing what happened in the week-long program,” Watson said. “We fixed
flash sterilization, and increased the capacity of the operating room to 16,000 cases.
We invested in one flat-screen TV, and we took down one wall. We have a sterile
processing department that could handle all the work that was there and more without
expanding one square foot.
Continuous-improvement ideas contributed by clinical
coordinators from Akron Children’s Hospital
Radiography School program.
“And now, we’ve done two capacity studies on surgery, and we are running at 64
percent. It will take 2.5 years, but we want to get to 85 percent efficiency, which would
mean around $15 million in additional revenue in the same operating room with
essentially the same people.”
Low-Tech Solutions Increase Customer Value
In addition to increasing the number of procedures, the hospital is focusing on patient
Value in the form of decreasing wait times and increasing accessibility to doctors and
services. This supports the goal of being the No. 1 choice for Northeast Ohio parents.
Outpatient doctor visits was an obvious place to start. If there is any customer who is
most deserving of getting more from service providers, it’s a parent with a sick child.
Emotionally drained and frequently exhausted, such parents Value predictability and
kept promises. Less time spent at the doctor’s office means more time to take care of
themselves and their families.
The doctors, nurses, and other employees at ACH’s Locust Pediatric Care Group know
this. When deciding on a Process improvement goal, their focus was reducing the
amount of time that established sick patients spend in the clinic. By its nature, the clinic
is an unpredictable place as patients stream in from the city of Akron and surrounding
urban and rural communities. Many of the children are poor, recent immigrants, or in
foster care. All of them have potentially complex social and medical needs, and all of
them receive care regardless of ability to pay.
Through a series of kaizens and A3-based project planning and implementation, the
Locust team identified and implemented a number of improvements that reduced patient
in-clinic time from 70 minutes (2009) to 43 minutes (2011). Significant improvements

Converting paper charts to electronic medical records, which helped to
streamline the information flow.
Implementing visual whiteboards that track patient flow during the appointment.
Adding a team-wide “huddle” at the start of the day to prevent problems, such as
scheduling issues.
Eliminating triage rooms — where patients would be evaluated for priority of care
— instead using mobile triage carts in the exam room.
The team is working on more definitive documentation, but early feedback is that
customer Value has increased.
“Office flow and access are the two biggest areas at Locust Peds where we can meet
and exceed expectations from our patient families,” said Cindy Dormo, vice president
for Pediatrics. “Now we’re measuring patient throughput and reviewing feedback from
patients, which in the past has included complaints about long wait times, but is now
turning favorable.”
Blue Belt Training Brings More People In
Dormo and other top-level executives said a key to the COE’s success is a focus on
engaging all levels of the organization. Most recently, the COE team created a Blue Belt
training program to focus on department and functional leaders, positions that would be
considered “middle management” in a corporate setting. According to Dulin, the Blue
Belt program is another example of how the COE program is directly supporting
strategic growth goals.
“Our goal is to have this touch everyone. We then have everyone supporting the
hospital’s goals, which then improves all of our major systems,” Dulin said.
Taking advantage of interest and enthusiasm generated by the MRI project’s success,
the COE team chose the radiology department for the first Blue Belt training program.
Every lead technologist, supervisor, manager, director, radiologist, the department chair
and vice president participated.
Blue Belt participants learn how best to use the talents of their staff to streamline
operations, improve the quality of care provided, and reduce variability and waste.
Lessons focus on daily communication among staff members and leadership, learning
how to track and improve daily metrics, and creation of standardized processes that
stabilize patient flow.
The Blue Belt program is spreading to other departments. The plan is to begin with
Dept. of Pediatrics employees, and then expand to surgical subspecialties, the Akron
Children’s Heart Center, and Neurodevelopmental Sciences Center. In all at least 300
employees will have completed or been affected by Blue Belt training by the end of
Lessons Learned and a New Opportunity
Watson, the hospital executive who introduced continuous-improvement at ACH,
identified these key factors as contributing to the COE’s early success:
Founding COE leaders: “After the decision was made to go with lean, I spent almost
three months selecting people from our organization to help us on our lean journey,” he
Watson purposefully chose individuals who were successful, respected by their peers,
and brought diverse backgrounds to the effort. These included a doctor with lean six
sigma knowledge, a pharmacist who had just completed her Pharm.D., a medical
technologist, a nurse, an M.B.A., and an administrator.
From left, Dr. Mike Rubin, Dr. D. Scott St. John, Dr. Godfrey Gaisie, and Dr. Azam
Eghbal from the Radiology Dept. hold their daily accountability meeting as part of
continuous-improvement Blue Belt Training.
Watson also stressed the importance of having a practicing physician on the team.
When Dr. David Chand joined ACH after working as a consultant, he dedicated 20% of
his time to the COE and the rest to seeing patients. His role in the CEO has since
expanded to about 90% of his time, but he will always see patients.
“When you are dealing with physicians, in order to be considered part of the club, you
really need to have a stethoscope and see patients,” Watson said. “They like to interact
with other physicians who are seeing patients. That’s just the way it is.”
Chand has been invited to work on improvement projects in many areas of the hospital
and has become the go-to man for other doctors interested in learning more about the
COE, some of whom are in the Process of green-belt certification. His personal A3
projects have included removing non-Value-add time from the residents’ patientrounding Process (daily in-person visits to patients).
Investing in education and training: Watson said an additional attribute that he
looked for in team members was a quest for life-long learning.
After he assembled the team, Watson immediately sent them to a lean six sigma
program at Johns Hopkins University, which included six weeks of learning over a fourmonth period of time (with project work done at ACH). The team then spent a week at
Seattle Children’s Hospital to observe and learn from that CI program. In 2010, two
team members received master’s degrees in operational efficiency and black belts from
Ohio State University. Three others are now going through the course and will graduate
in 2011.
Additionally, several department VPs have attended classes at Johns Hopkins and
programs at Seattle Children’s Hospital.
“But we made a mistake,” Watson said. “When we started, we started with our front-line
people working on projects with the A3 Process. And we had very good engagement
from the executive level, vice president and above. But what we left out was that middle
manager level.
“Now the middle managers are really enjoying and learning with the Blue Belt program.
The A3 Process works much better now that we’ve covered the entire organization in
terms of learning what we are doing. Our tagline is Process improvement through
people development.”
Accepting failures/celebrating success: Not every project will be successful, Watson
said, “and if they are all successful, you are not taking enough risks.”
ACH’s ambition is being noticed and rewarded outside of its own facilities. This year, it
was awarded a contract by a third Cleveland hospital, MetroHealth Systems, to provide
pediatric care in cardiology, gastroenterology, cancer and blood disorders, and critical
“We are impressed by how fully Akron Children’s is integrated into the region, how well
it has partnered with other hospitals, and its growth, having added 77 individuals to its
medical staff in 2009,” said Margaret Stager, chair of the Dept. of Pediatrics at
MetroHealth. Previously, UH pediatric specialists were contracted to provide the
Akron Children’s Hospital Center for Operations Excellence
A3 Program

Started in January of 2009
Eight-week Lean six sigma Training designed for the people who do the work on
a daily basis
Projects are done on A3 paper using the DMAIC (Define, Measure, Analyze,
Improve, Control) methodology
Meet weekly for two hours of class time and one hour of coaching
Green Belt Program

10 Green Belts certified through Johns Hopkins Center for Innovation in Quality
Patient Care

20 Green Belt candidates working on certification through Akron Children’s
Hospital’s Green Belt Training Program.
o Candidates and projects selected by hospital leadership
o Ten days of training and project work spread out over five months using
DMAIC methodology
o Tollgate session at the end of each DMAIC step
kaizen Program

Two-to-five-day rapid Process improvement events
Strategically driven by hospital leadership
Multi-disciplined teams that cross over Value streams
Key stakeholders from the Value streams work together to solve problems and
implement solutions
Blue Belt Program

Manager/Leader Lean six sigma training for departmental certification
Basic understanding of Lean six sigma principles and tools: gemba walks, daily
huddles, Value stream maps
Links with Related Information
Akron Children’s Hospital: As the largest pediatric healthcare provider in northeast
Ohio with hospital campuses in Akron and the Mahoning Valley, the dedicated team at
Akron Children’s Hospital promotes the well-being of children now and in the future. We
perform more than 600,000 patient visits each year at more than 85 locations. Our
specialists care for infants, children, teens, and adults treating a wide range of
conditions from routine primary care to the most complicated injuries and illnesse …
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