Greetings from the Operative Services team here in Japan. After two days in Nagoya, we traveled south, arriving in Fukuoka late Sunday evening, where the rain greeted us again. We spent all day Monday in classes learning about Kaizen from our four senseis. We studied just in time, standardized work, kanban systems and flow of materials and information.

“Although we have been working on many of these concepts already, we are learning that we have just scratched the surface of our leanings and the importance of constantly building “iterations” on the work we have already started,” says Cheryl Tada.

Monday ended with a traditional Japanese dinner where some of us were found to be more adventuresome than others.

“The culture and people have made us feel very comfortable. We are learning the Japanese way and trying not to disturb the “wa” (harmony),” says Eli White.

Even with limited Japanese language skills, we have been able to find our way (mostly), order food and understand the flow of work in the factories. The use of visual cues is everywhere along with a service culture that is unmatched. We have seen airline workers and immigration officials running in the airport terminals to assist passengers. Hard to believe for those accustomed to air travel these day perhaps, but true!

Another example of service excellence was provided on our last night in Fukuoka when a group of us set out to find the famed street-side food stalls located downtown. We must have looked a little lost as we were spontaneously adopted by a local businessman who took time to detour from his trip home and escort us to our destination.

The past two days we spent going to “Gemba” at Showa Manufacturing. They specialize in various heating and air conditioning equipment and have been practicing Kaizen (lean) for over 20 years. Judy Dougherty “saw standard work in action that clearly allowed the worker time to be creative and to continually improve the process. Furthermore, intuitive layouts supported the training of new workers.”

Sean Flack was “surprised by the craftsmanship and variety of custom work evident in a factory setting.” Clearly, manufacturing environments have more in common with our workplace than we might intuitively expect.

As Ti Refvem commented “many ideas can be taken from the factory floor and used in our setting. The factory workers use a combination of manual techniques and high-tech machinery to service our customer. We also do this in health care”.

Today we traveled an hour by bus to two car manufacturing plants. We first visited the Nissan plant in Kyushu where we were left speechless by the extensive use of robots to perform many tasks. Who would have thought that we would be reminded of ballets and waltzes while watching these machines perform their work?

Then we were privileged to travel into the hills outside town to the Toyota plant where Lexus and Highlander models are made. Again, we were awed by the synchronous work of man and machine. As Jeremy Guideschek observed, “it’s all about the flow”. Unlike Nissan however, Toyota has clearly chosen to rely less on robots, and with careful thought provides a safe and supportive environment that promotes worker excellence.

Thanks for reading our blog and we look forward to reporting to you all in person on our return to Seattle.

The Operative Services Team

…striving to stay ahead of the times.” This was the core philosophy of Sakichi Toyoda, founder of what is today’s Toyota Motor Corporation. While in Nagoya, our first stop during the Japan CPI trip, the Radiology team had the opportunity to tour Toyota’s Commemorative Museum of Industry and Technology. This unique museum successfully takes you through Toyota’s early days of textile looms (late 1800s) to future focused human design. It was truly a rewarding experience for the Radiology team. We have included a photo showing six of our team members with their sketching pads at the ready.

The team sketched extensively throughout our time in the museum (see photo of Ray Ramoso hard at work). During our team debrief (an exercise every team participates in at the end of each day) we identified 3 key learnings from our museum visit: 1) The 3 Is of success - incremental, iterative improvement; 2) The power of the 7 design principles which include “flexibility in use” and “simple and intuitive”; and 3) start small with reliable methods - in other words don’t hesitate too long before you jump in and begin a cpi project or pilot. Speaking of reliable methods, this is one of the implications for the Radiology team at Children’s. We agreed that we need, as a pilot project, to pick a specific area in Radiology to begin focusing on reliable methods and to get on the road of incremental, iterative improvement. In addition, we resolved that we need to understand our current processes better by collecting and analyzing data and via first hand observation.

During our bus ride back from the museum our discussion always led us back to the core reason for Toyota’s great achievements - an unwavering belief that they could be successful. This was clearly demonstrated by Sackichi Toyoda’s son, Kiichiro, who in 1934 moved the company into car production when many said it could not be done by a Japanese company. What you realize when you go to Gemba and see Kaizen (continuous improvement) principles in action is that it requires a strong, long term commitment to continuous learning and improvement.

We look forward to learning about more ways to improve our Radiology value stream as our trip continues and sharing some of these learnings with you in our next blog entry.

The Radiology Team

The ED team completed a great first day in Nagoya, Japan. After a perfect flight from Seattle to Tokyo, a connector flight to Nagoya and an informational bus ride to Nagoya Central, the team settled in and prepared for a visit to Nagoya castle, which was built in the 1600s.

The visit was designed to enable individuals on each team to look at an unfamiliar area and process, collate their observations with each other and the other groups (OR and radiology), and relate those observations to our work environment and opportunities. This process was aided by sketching what we saw.

It was amazing to perceive the same area and structures in different and unique ways. While some focused on macro-structure, others saw the intricate design elements as their primary observations. Others saw the surrounding environment, while several individuals concentrated on the people involved. It reminded us of how we look at things through eyes and minds with diverse training and backgrounds, and often see different aspects of the same process, or the same picture in different ways.

A few of the major take home points for us included the following. Some noted that the visible structure is built and predicated on the infrastructure, which is intricate, but clearly thoughtfully planned and implemented. The solid structure of the castle walls reminded us that although the load bearing walls might be solid and uniform, the structure of the remainder of the walls was variable and unique, not unlike the multidisciplinary and unique individuals who make our institution function on a daily basis.

As we intently looked and sketched our areas, we were also reminded that first looks are indeed just that. We missed several key observations on those short assessments, reminding us of the need to go to the source often to experience the environment and learn, rather than look once and assume.

It was also obvious to us that although the surroundings were extensive and beautiful, they were somewhat overwhelming to us, even as tourists. We projected that feeling to how our patients and families might feel in our large and expansive facility. Although it is comforting to us as employees to work in a superb institution, it can be overwhelming and stressful for our patients and families, who not only have to contend with a new environment, but also manage the actualities of the illness, injury or other issue that has brought them to us.

It is our people who make the facility what it is and we are the ones who can make the building friendly and patient/family centric, as well as manage the medical concerns in a consistent, standard and quality fashion. As we viewed a facsimile model of several workers, connected by a rope and working in unison, who were tasked with moving a huge square building rock, it reminded us that the impossible and the unbelievable can be accomplished by teams that work together to provide safety, design a process and monitor results.

Together, working on the small as well as the large opportunities, we too can accomplish what might be thought of as impossible. Results might include service on demand with no waiting for care or interventions regardless of the time or day and medical processes without waste.

This has been a great first day of lean immersion and we are excited to continue our journey as CPI students and teachers. We look forward to sharing more information with you as we continue in Japan and upon our return.

May 31, 2008

The ED Team,
Dawn Cotter, Russ Migita, Kendra Powell, Amanda Mogg, Mark Del Beccaro, Cara Bailey, Connie Whillock and Tony Woodward

Another group of excited Children’s team members has gone to Japan!

They left on May 29 for two weeks of intense learning about continuous performance improvement methods and work. The group will visit many companies that use Toyota’s lean methods and look for ways to apply these techniques back at home.

The group is a broad representation of the hospital, including staff from the Emergency Department, Radiology Department, Operative Services, CPI Department, Marketing Communications and more.

Watch for posts on this site from each of the teams. Team members include:

Emergency Department Team

• Tony Woodward
• Dawn Cotter
• Russ Migita
• Amanda Mogg
• Kendra Powell
• Cara Bailey
• Connie Whillock
• Mark Del Beccaro

Radiology Team

• Ed Weinberger
• Chuck Fritz
• Ray Ramoso
• Randy Otto
• Lisa Brandenburg
• Barb Bouche
• Emily Camm
• David Perry

Operative Services Team

• Cheryl Tada
• Jeremy Geiduschek
• Tony Avellino
• Pat Hagan
• Judy Dougherty
• Sean Flack
• Ti Refvem
• Loan Lam

Wishing them safe travels. Check back here for real-time reports from across the planet.

Today was a day of reflection from this week of Kanban immersion training. While there are many information nuggets (such as using flexible PVC pipe to construct inventory racks) some of our most significant learnings are listed below:

There must be a stable process to have an effective Kanban system. If processes are highly variable/unpredictable a pure visual signal such as kanban is not effective. This is because the kanban is set on one cycle. The cycle works in a loop, so the loop must be in the same rotation over and over.

The role of the water strider (materials handler moving from station to station). This position allows the operator to focus on their core role/activites, while a resource dedicated to distributing supplies and equipment works around the operator to ensure they have what they need, when they need it.

Kanban at its core is visual. Everything about the kanban system is visually triggered. From the simple information on the card, to the limited flow pattern, everything about the process is easy to follow. The simplier the better.

A kanban should have a single purpose. The kanban triggers resources from point A to point B. It then returns to A for redeployment. It should be considered a round trip non-stop ticket.

Do not start work until a kanban is received and only produce what is requested. Kanban is a vehicle for standard work. If you start work prior to the signal, or work beyond what is required, you are contributing to the waste of overproduction (mira).

Placement of supermarket is key. Systems need supermarkets (inventory hold locations) to maintain flow between supplier and production points. It is critical to understand where the supermarkets are, what they hold, how resources flow through them, and how they are maintained.

Kanbans require continuous refinement. After implementation, assessments of performance become key. It is critical to ensure kanbans flow is controlled. Kanban replenishments should never be too “hot” (requiring many replenishments ) or “stale”, but should always be in synch with customer demand.

Establishing Buffer (safety) stock requires diligent study. Levels of buffer stock accommodate processes variability. However buffer stock should be defined with quantitative tools, reviewed with frequency, and established with purpose recognizing criticality and severity of the item.

Kanban does not create standardization, but it does rely upon standardized processes. Customer orders can be diverse (ie: different models and accessories on cars coming down an assembly line) but the items delivered to support the assembly process should come the same way every time.

Kanban is not a universal tool or solution. It does not fit all applications. It is a vehicle for flow but not always applicable. Sensei Niwa asked the question “Do you need a kanban card to tell you that you are hungry?” You want to develop systems that automatically pull the right supplies. Until you reach the point of innate pull within the system, the kanban can be the right answer.

The Supply Chain team has discussed plans for piloting a simple kanban system based on these learnings that can be started within the hospital and rolled out to the outpatient clinics. The goal is to remove the clinical staff from the supply replenishment process. This can be an iterative improvement on some of the early kanban systems that have been established.

This spring we will be working with our Tauber Institute (industrial engineering graduate students) interns to apply kanban approaches to some supplies in the OR core area and to the case cart process. Included in this work is possibly changing from the notion of case carts to case “kits” meaning that the OR is provided with exactly what is needed, for a case as it is needed. This would be a true kanban application.

Kanban - A system that ensures the required parts are received when they are needed in the volumes they are needed.

At the end of this Kanban instructional journey are the Black Belts of Kanban, the Toyota plant and one of its primary suppliers, Toyota Boschoku. Toyota Boschoku started in 1914 as a spinning and weaving company. The production line of the Toyota Tsutsumi plant (making the Camry and Prius) communicates to the Boschoku via e-Kanban in a continuous fashion during the working day. This kanban notification to Bobuschoku set their paper Kanbans into motion. Boschoku is the supermarket for the Car assembly line and they have various production lines within their factory.

Boshoku make 610,000 pieces monthly, for 23 different customers. Boschoku has 180 inventory turns per year. This means that they deplete and replenish their inventory every 18 hours. In order to do this they must be completely in sync with their customers demand on a moment by moment basis. Kanban helps them make this connection. Each day they handle 20,000 kanbans.

One application of the kanban was in support of one of the assembly cells. This was a one person work cell. A kanban card was swiped by the operator and the materials were provided to him. The materials were perfectly positioned for his work and included the standard work instruction for the piece he was assembling, appearing on a monitor directly in front of him. To his right the correct tool tray was automatically unlocked for use to make sure he had the right tools (poke-yoke).

The plant has all the lean elements to perform significant manufacturing. They focused on flow, die turnover and making sure that they meet customer demand. A strange similarity is that the Toyota Boschoku plant building has a serrated roof line that looks exactly like the symbol for “supplier” in our Value Stream Maps.

The main event was shown in the Toyota Tsutsumi plant. Receiving shipments every hour during the workday, they quickly use and refill the 30,000 parts required to build a Prius or Camry. They build 34,000 cars per month at the plant in two shifts. The goal for the line we observed was 288 cars. They were running at 97% of this goal as we observed the process in the afternoon. The takt time for the line has a car finishing every 3.3 minutes. Their lead time is 20 hours.

Dollies holding parts and tools accompanied the body down the line. Just like in the one-person cell each station had an instruction sheet for the particular car at the station. Kanbans were so integrated in the flow of materials that it was hard to see any differentiation between the kanban and the arrival of the materials.

One place where they did not use kanban cards was in final door installation. Each door was perfectly matched to the main vehicle body. The doors were removed after painting to allow improved access for installation and to avoid cosmetic damages. The removed doors continued along at exactly the same rate as the body and they arrived in the precise order needed at exactly the right time. The kanbans are unnecessary.

Tomorrow we will be discussing lessons learned and steps for Kanban at Children’s

Tuesday was all theory. Lectures on the Kanban applications, simulations, and case studies. Kanban involves looking at demand looking at stable level loaded processes, establishing Takt time and making calculations on the number of Kanban cards and reorder points.

We started our day at Yokohama Bay and had a chance to see many of the Kanban applications we have been taught and seen simulated in the two day prior. Yesterday’s progression had us on the factory floor at Yamatake. Yamatake is a manufacturer of control valves, flow and pressure meters. In business for thirty years, the company has embraced Lean manufacturing but admit that they have much to improve in their Kanban application. We broke into three teams mixed with members from Children’s, Park Nicolet, and Genie Industries, and hit the manufacturing floor. We studied our assigned line operations. We looked at the supplies and activities in an attempt to make recommendations to improve flow through the use of Kanban and Heijunka. We adjusted operating start times, expanded the supply distribution role (Water Strider) and recommended that the operations move from box Kanban to a Kanban/Heijunka Production board. We presented how our models would improve efficiency and were happy with our breakthrough work. After the presentation, Sensei Niwa thanked us for our efforts and saw fit to give us a C- for our recommendations. Sensei Niwa emphasized; “Reduce the number of Kanbans. Kanban should be the express train through the factory. The important lesson is to keep the operator at the station, use water striders to move materials. “Continuous refinement of the process is essential.”

Yamatake managers were not as critical in their closing remarks, quite the contrary. Our gracious hosts walked us back to our bus and waived continuously until we were out of sight. The next morning had us back on the bus headed to Yokohama Rubber company. Yokohama is famous for it’s tires and hoses, which count for 70% of their revenue, but they also produce products you would not expect from a rubber company. The line we visited at Yokohama manufactures lavatories for the Renton built Boeing 737’s. Yokohama uses moving assembly lines and has employed an elaborate Kanban system to move parts from their vendor community through their super market (central stores- like parts warehouse) to their assembly line.

There were obvious maturing improvements in the Yokohama line that we did not see at Yamatake, the management at Yokohama stated clearly that they have a lot to learn with many more iterations of Kanban ahead. Their Takt time is currently at 110 minutes which results in 90 minutes of overtime each day. Their Kanban supply board revealed that several part deliveries expected from their vendors were 2 - 4 days late. An obvious needed for improvement, at least the problem is visible and being managed.

All these companies showed a journey with Kanban development which parallels the entire lean experience. Tomorrow we will be visiting Toyota, the un paralleled senior organization in Kanban.
Later in this week we will be looking at the Supply Chain Value Stream to discovery the various applications of Kanban at Children’s. We know that Kanbans will be a journey of trials and constant refinement requiring that we look hard at establishing predictable and leveled demand.

The Power of Visual Signals

One of the first lessons learned is that Kanban means visual signal. As our delegation spent our first full day (Sunday) in Tokyo we discovered a common sense of empathy with Children’s families. Families arrive at the hospital doorstep even less prepared for the language, culture, and rules of the hospital than our group in our first day in Japan.

In downtown Tokyo we found that simple things can be confounding if you do not understand the language. At a buffet line we were challenged to open the lid on the electronic rice cooker when all the buttons were labeled in Kanji. We abandoned the rice option feeling child-like in our inability.

Our team discovered the magic of symbols and pictures paired with willing, helpful people. With these aides we were able to take subways, buy items and for the most part order what we wanted for dinner.

We plan to take this experience back to Seattle and hopefully see the world of Children’s a little more through the eyes of the Spanish speaking family from Yakima, or the Alaskan mom and daughter that in the day prior were in the clinic of their remote Aleut village. Based on this experience we will be looking for evidence of signs, symbols and helpful people that will translate and assist these families in the foreign land and experience at Children’s.

In the days ahead will we be working through simulations featuring the different types of Kanban systems. After the simulations and lectures we will be visiting factories such as Yamatake, a supplier of bathrooms to the Boeing 737, to actually work through the process of extending the number of kanbans used in their plant.

The challenge ahead is first to thoroughly understand the Kanban process and then start to dream about the applications. We look forward to sessions involving quite a bit of math and hoping that in the instruction we will have plenty of signs and symbols.

Today, another group of five Children's leaders is heading out to Japan with a new mission: to learn about "lean" methods for pulling resources through our various processes (supplies, equipment, etc). It's all about making sure our staff have exactly what they need when they need it, at the right place, in the right quantity, and at the right cost.

Continue reading "Mission "Kanban"" »

Greetings from Hone Chimu (the bone team), aka the Samurai Tuna Cutters. Chappie was very impressed with the tuna cutters at the Nagoya fish market. He says they would make excellent orthopedic surgeons!

Continue reading "Greetings from Hone Chimu (the bone team)" »