Kaizen is a Japanese word that means “change for better.” It entered the American vernacular during the manufacturing quality crisis in the 1980s as American companies began to emulate Japanese producers who had surpassed them in quality.[1]  A decade later, on the heels of publications such as To Err is Human and Crossing the Quality Chasm, the healthcare industry found itself in a quality crisis of its own—ever-increasing costs and stagnant quality performance. [2]^,[3] Like manufacturing, healthcare looked to Japanese organizations like Toyota to discover best practices in improving quality.  Kaizen taught American industries two important lessons about improvement. The first is to foster a culture that enables effective problem solving. This means creating a shared vision, empowering the workforce to think critically, and presuming that problems are created by processes rather than by people. The second lesson was to use effective problem solving methods. These methods called for interdisciplinary teamwork, problem visualization, root cause analysis, and rapid experimentation.[4] Since the 1980s, both lessons have been embraced by the healthcare industry and mostly practiced in-person. This is because students of the Kaizen learn that a deep understanding of a problem can only be achieved by observing the problem first-hand.[5] They also learn that Kaizen requires rapid experimentation which usually can only be done on-site, in person. Social distancing measures which accompanied the pandemic rendered in-person activities next-to-impossible. Did COVID-19 kill the Kaizen? Natural history teaches us that when environments change drastically, the habitants face two choices: adapt or perish. Here, I argue that not only has pre-pandemic Kaizen survived this shock, but has evolved to become stronger. Observations are now more intentional, there is less waste in the process of problem solving, and new, more effective tools have been discovered to solve complex problems.

First, how can Kaizen occur without in-person observation & testing? Answering this question forced healthcare improvement practitioners to contemplate the process of observation. In pre-pandemic manufacturing, Kaizen was facilitated on-site where observations can conveniently be conducted with a short walk to the floor. Healthcare practitioners also learned to facilitate Kaizen this way, but the observation process was not made easier like it was in manufacturing. This is because, unlike manufacturing, many healthcare processes are invisible and asynchronous. Even before the pandemic healthcare workflows were carried out in electronic systems, by different people, at different and often unpredictable times. For example, imagine attempting to observe a patient discharge. When will the attending place discharge orders? When will post-acute placement be arranged? Occupational health assessment? Pharmacy consultation? The most common answer to these questions: “It depends”. For this reason, observing and experimenting in healthcare was challenging long before the arrival of COVID-19. When Kaizen moved into the virtual realm, improvement practitioners were faced with an important question: how can the problem be observed? The answer, surprisingly, is the same as it was when Kaizen was done in person! Healthcare observations must be planned and scheduled. Rather than conveniently, and sometimes haphazardly, conducting observations and tests, careful thought must now be given to maximize the value of both activities. In this way, social distancing protocols made observing and testing more likely to be productive by prompting teams to consider what they are going to observe, how, and why. In addition to adding value to the observation process, COVID-19 has revealed opportunities to reduce waste in the logistical aspects of improvement.

The purpose of Kaizen is to increase value and decrease wasteful processes. Ironically, Kaizen activity itself contains a significant amount of wasteful activity. Facilitators must identify a venue that satisfies both problem solving needs and the needs of the attendees. Then it must be reserved, seating arrangements must be determined, and driving directions must be distributed to participants who might not be comfortable with online maps. Also, refreshments will need to arranged for participants along with supplies that will needed for problem solving exercises. These wasteful but necessary preparatory activities for in-person improvement can be eliminated when improvement is conducted virtually. Logistical considerations are reduced to things like ensuring all participants have a link (and password, if necessary), a device that will enable them to join the event, and a camera to share their image with the group. Admittedly, there are still things that can (and do) go wrong with virtual gatherings, but are far less frequent, less disruptive, and usually easier to troubleshoot then a broken projector.

Free from the burdens of logistical planning, virtual Kaizen has enabled facilitators to focus on more important work: how to get better at improving. A Kaizen traditionalist may wonder, how does one problem solve without sticky notes, white boards, and dot stickers? Again, it is helpful to reflect upon why these tools became so integral to Kaizen in the first place. These everyday office items were used for consensus building: sticky notes to build models of processes, white boards to make abstract concepts visual, and dot stickers to facilitate consensus by voting. Virtual collaboration platforms not only have these tools; in many cases, they offer better versions of them. Cloud-based, virtual white board applications offer a virtual wall that can be easily (and collaboratively) adorned with virtual sticky notes. They can be drawn on, have real images pasted to them, and even come with their own inventory of stock shapes, symbols, and templates for users. Unlike in-person Kaizen—often plagued by hard-to-read sticky notes taking turns falling off the wall—virtual Kaizen allows users to zoom in and out as needed and save progress instantaneously. Gone are the days of facilitators spending hours taking pictures and electronically documenting Kaizen outputs at the end of the day. Furthermore, in-person Kaizen is constrained by wall space and participants’ access to the Kaizen room if they wish to make changes. Virtual events can leverage infinite whiteboard space that can be accessed and changed by any participant with the click of a button. Although participants lose the ability to communicate face to face, virtual meeting software offers many effective tools to satisfy communication needs as well. Most products offer text-chat and visual annotation features which provide a new opportunity to contribute for those participants who may be uncomfortable speaking in front of a group. They also offer built-in polling tools to quickly build consensus in a variety of formats: multiple choice, free response, and up-voting to name a few.

The COVID-19 pandemic challenged the status quo in many aspects of life. It forced the global community to make sacrifices, but it also provided the opportunity to reflect. Together, we considered: What is our situation today? Where are we trying to go? What stands in our way? How can we overcome the barriers? What can we try next? What do we hope to learn? These questions are core to what Mike Rother describes as the Toyota Kata, or leadership routine.[6] These “Kata questions” aid critical thinking to navigate an environment that is constantly changing. Unexpectedly, the answers steered improvement practitioners away from norms once thought to be must-haves for improvement. The answers lead improvers to discover better ways of improving than ever before. Most importantly, the answers to the Kata questions prove that COVID-19 did not kill the Kaizen, and that the next shock to the status quo won’t either.

Written by Hurley Smith