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. 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. , 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. 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. 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. 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
 Crawford-Mason C. If Japan Can, Why Can’t We? [Internet]. 2021 [cited 11 February 2021]. Available from: https://youtu.be/vcG_Pmt_Ny4
 Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
 Womack J, Jones, D, Roos, D. The Machine that Changed the World: The Story of Lean Production– Toyota’s Secret Weapon in the Global Car Wars That Is Now Revolutionizing World Industry. New York, NY: Free Press’ 2007
 Rother, M, Shook, J. Learning to See. Cambridge, MA: Lean Enterprise Institute, 1998.
 Rother, M. Toyota Kata. McGraw Hill Education. August, 2009.
Written by Hurley Smith
Karen Frush, MD, is the former Chief Quality Officer at Stanford Health Care. She is a Clinical Professor of Emergency Medicine and Pediatrics. She also serves as a member of the Stanford Medicine Center for Improvement Advisory Committee.
Dr. Frush has been an MCHB funded researcher and helped lead an effort funded by the CMS Innovation Center to improve patient safety and quality across 70 small community and rural hospitals through the LifePoint Hospital Engagement Network. LifePoint was recognized with the John M Eisenberg Patient Safety and Quality Award in 2017 for this work. Dr. Frush has published peer review manuscripts in the areas of pediatric emergency care, patient safety and quality, teamwork, safety culture, interprofessional care, and quality improvement, and she has authored multiple books on these subjects, including Improving Patient Safety through Teamwork and Team Training, with Eduardo Salasin 2012. She is a Team STEPPS Master Trainer and served on the Department of Defense, Team STEPPS Technical Expert Panel (2008-2010). She is an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship program, served on the American Academy of Pediatrics Steering Committee for Quality Improvement in Pediatrics(2006-2011), and has been named one of 50 experts leading the field of patient safety by Becker’s for the past five years. She served on the Board of Advisors and the Board of Directors for the National Patient Safety Foundation and currently serves as Chair of the Institute for Healthcare Improvement (IHI)Certification Board for Professionals in Patient Safety.
Former Leadership positions include Chief Patient Safety Officer of the Duke University Health System (2004-2018); member of the Board of Trustees, North Carolina Center for Hospital Quality and Patient Safety (2005-2012), and Vice President for Quality, LifePoint Health and Duke-LifePoint Healthcare (2011-2018). Dr. Frush received a BSN from the University of Pittsburgh School of Nursing and then attended the Duke University School of Medicine where she earned her MD.
Alice R. Georgitso, MPH, joins the SMCI Advisory Committee as our first Patient Partner. Alice has served as a Patient Partner with the Stanford Health Care (SHC) Patient & Family Partner Program for over 4 years and was appointed Chairperson of the Adult Congenital Heart Program Patient & Family Advisory Council in January 2020. She assisted in developing the Stanford Adult Congenital Heart Program’s Peer-to-Peer Program and serves as a Mentor to ACHD patients pre-and-post-organ transplantation. Alice has presented Stanford Health Care’s C-I-CARE framework for structuring best practice communications and developing relationship-based care approaches with patients and colleagues to 500+ Stanford Medicine Directors, Managers and Clinical Staff.
Alice is a Patient Relations Manager at Stanford Health Care. Within her role, she provides a channel for problem resolution to promote the highest quality of care and service excellence. Alice has also worked as an Unrelated Donor Search Coordinator with the Blood & Marrow Transplant at Stanford Health Care to coordinate allogeneic hematopoietic stem cell transplants through collaborative planning and partnership with the National Marrow Donor Program and SHC clinicians. Prior to her work with SHC, she was the Community Service Foundation Director at San Mateo County Medical Association where she partnered with local stakeholders and clinicians to expand county-wide community health programs to diverse populations. She has also delivered invaluable community health services through her work with the American Heart Association.
Alice earned her Bachelor of Arts in Sociology and Biology at Saint Bonaventure University in Olean, NY and her Master of Public Health from SUNY Buffalo in Buffalo, NY. Alice is a member of The Beryl Institute and Adult Congenital Heart Association professional associations, Donor Network West partner advocating for organ, eye, tissue, and blood donation, and remains an active volunteer with SHC. Alice continues to promote patient-and-family-centered care in both hospital and community settings to support precision health and improve the healthcare experience for patients, families, and clinicians.
John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota's headquarters, he became the company's first American kacho (manager) in Japan. In the U.S., Shook joined Toyota’s North American engineering, research and development center in Ann Arbor, Michigan as general manager of administration and planning. His last position with Toyota was as senior American manager with the Toyota Supplier Support Center in Lexington, Kentucky, assisting North American companies adopt the Toyota Production System. Shook co-authored Learning to See, the book that introduced the world to value-stream mapping. He also co-authored Kaizen Express, a bi-lingual manual of the essential concepts and tools of the Toyota Production System. With Managing to Learn, Shook revealed the deeper workings of the A3 management process that is at the heart of Toyota’s management and leadership.
Shook is an industrial anthropologist with a master’s degree from the University of Hawaii, a bachelor’s degree from the University of Tennessee, and is a graduate of the Japan-America Institute of Management Science. At the University of Michigan, he was director of the Japan Technological Management Program and faculty member of the Department of Industrial and Operations Engineering.
Shook is the author of numerous articles, including "How to Change a Culture: Lessons from NUMMI"; Sloan Management Review, January 2010, which won Sloan’s Richard Beckhard Memorial Prize for outstanding article in the field of organizational development.
The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.
Dr. Paul Maggio is the Chief Quality Officer of Stanford Health Care. Prior to being appointed the SHC CQO, he was Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.
Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013
Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.
Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.
Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.
As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.