We have just enjoyed a day of rest in Kyoto after many others of travel and visiting assembly plants, where the sheer pride and joy in “making things” is palpable. At first, some of us questioned how line operators remain engaged and focused in their work but we soon recognized why manufacturing is so valued in this culture. The Toyota spirit of being studious and creative is evident in each place we have visited. There is reciprocal respect between each worker and their commitment to improvement.

In these places it is so easy to see that when standard work and flow are in place the entire workplace is less chaotic. The workload is balanced and little needs to be said among the operators when one picks up where the other left off. Watching their teamwork is like watching a well choreographed ballet or a fantastic soccer game. We are in large factories but the environment is surprisingly serene. Similar to the airplane simulation, which many of us have experienced, people are not working harder or faster, just smarter. There is little chatter among the workers because there doesn’t need to be.

We have seen many innovative enhancements and realize that standard work and removing waste is the foundation for incremental improvement. Likewise, an organized environment is critical for flow. We have seen that having a space that is 5S’d does not necessarily guarantee flow, but it is clear that flow cannot be accomplished without it. This simple idea provides a starting place for all of us whether or not we are involved in RPIWs or focused program value streams.

Lastly, we have been struck by the impact of the economic crisis and the renewed emphasis on removing waste as the primary strategy for cost reduction. The scope of projects is kept small which allows the change to happen with little disruption to the line. We have seen examples where small improvement efforts occur in the moment through collaboration with members of their Kaizen Production Team (the equivalent of our CPI staff). We are challenged but optimistic about creating ways to expand CPI efforts and making CPI our daily work.

We are back on the bus and looking forward to the grand finale or the final minutes in overtime (choose your analogy) as we head towards Toyota City. I look around and see some tired faces but also a confirmation that this was worth every second…..

12 hours later… “Absolutely awesome” may be the only way to describe what we have seen at Toyota. Seeing the big picture, an example of true flow and the synchrony of assembly lines and materials has allowed us to envision what is really possible for our patients.

Mikhail Baryshnikov and the folks at the Federation International Football Association (FIFA) would be envious of what Toyota has accomplished. We also come away with a renewed commitment to make sure that our staff have all the resources they need (not more or less) at the right time and in the right place.

-Debra Gumbardo and The Transplant Team

As our Japan trip progresses we continue to learn by sketching, sharing our observations with each other and discussing concepts with our sensei.

Our first manufacturer visit was to Yamatake’s Azbil Shonan factory. We observed their control valve manufacturing line. Like Children’s, Yamatake has tailored the Toyota Production System to their own environment. For example, as their foundation they modified 5S into 5S + 1S. The sixth S stands for ‘smile’. Another concept we saw was implementing simple, low cost solutions. We saw examples such as work benches that were made out of simple, modular components like an erector set allowing the fixture to be modified and moved when needed. We need to take advantage of our creative minds and develop our own simple solutions instead of spending money on expensive items in health care that may not fully meet our needs.

On Wednesday we visited two musical instrument manufacturers. The first, Suzuki, manufactures harmonicas and melodions among other instruments. We began our visit with a brief musical demonstration by workers playing a Hammond organ and harmonica. During the factory floor tour we were impressed because we were able to see that too much inventory hides waste.

The second factory we visited on Wednesday was Yahama. We saw craftsmanship being done to a takt time. The creative work involved in tuning a piano was
completed within time parameters using standard work. We had a few moments
at the end of the tour to play some of the instruments in the showroom.
Steve Wanaka even had the chance to jam on the electric upright bass!

Today we visited another factory, Aisin, where we toured their aluminum casting and mattress manufacturing lines. We learned many things about inventory control. The sensei helped us visualize inventory as money sitting on the shelf. If we worked with our suppliers to receive medications 7 days a week we could reduce our inventory buffer and therefore
put money in the bank. We also saw a bidirectional kanban that went back
and forth between factory and supplier. The team thought this might be a
good idea to apply to the IV fluids in the pharmacy. The bin itself would
serve as the kanban going back and forth between the pharmacy and supplier eliminating waste and providing fluids just in time.

During one of our debriefs we also discussed the idea of using a third type of kanban signaling the flow of the medication preparation in the pharmacy.
This would help the pharmacy identify and prioritize patients who are waiting for medication administration in a clinic. By getting the medication out quicker, the patient could leave the exam room sooner.

We have been very fortunate to participate in this experience and are humbled and inspired by achievements we’ve seen. It’s clear that we can and will succeed in our CPI journey if we are persistent and dedicate ourselves to the right work.

Anne Bournay, Barb Marquardt and The Pharmacy Team

We are fortunate to be part of Children’s CPI trip to Japan and fourth journey as part of the Cancer program. We are joined by our colleagues from Transplant and Pharmacy and are enjoying spending time together.

We arrived in the bustling city of Nagoya on Friday evening after a day of travel and a day lost to crossing the international date line. The city is beautifully decorated for the holidays, giving us a sense of familiarity and reminding us of home. There are other familiar places - there is a Starbucks in our hotel and a McDonald’s right down the street!

We have been struck by the dense population of the area. In spite of the busyness of the streets, shops, and hotels, the service we have received throughout the city has been truly impressive. Customer service seems to be ingrained into the culture in a way which makes us feel very special and welcome.

Our first full day in Nagoya was spent touring Nagoya Castle and “learning to see” through sketching. At first, sketching seemed daunting to most of us but we all agreed it is helping us to see in a much more focused, detailed way than we are used to in our daily work. The castle is an impressive representation of flow and how beauty and function can be integrated.

Our second day in Nagoya was spent touring the Toyota Museum. We came away from this experience with a much deeper understanding of how continuous, small change over time leads to great successes - something we over-achievers are struggling to come to terms with! We recognize our instinct is to take on a big project in order to maximize potential benefit, but we have seen how small, frequent change leads to impressive results.

We then traveled by bullet train to the peaceful town of Odawara where we will begin to tour factories. Our Japanese senseis have spent the day reviewing CPI principles and preparing us for our learnings. Already, just a few days into our trip, we have many ideas for potential improvements in our work areas. We look forward to the remainder of our time to experience deeper understanding of these important tools and how we can apply them to make Children’s the BEST!

—Bonnie Fryzlewicz and Laura Winter

A team from Children’s is off to Japan to learn continuous performance improvement tools and techniques from the world’s experts. Representatives from the Cancer, Transplant and Pharmacy Departments are part of the eighth group to travel from the hospital.

Nagoya, Kyoto, Tokyo are stops on this 12 day learning trip spanning from Dec. 4 -16. Stay tuned for news and updates from overseas.

Hello!

It’s Saturday night in Japan and we’re in Tokyo, looking back on a very intense week of training, hands-on practice and reflection on the tools of the Toyota Production System.

Yesterday our three teams presented the results of our improvement workshops at the Yamatake meter plant to our sensei, the company’s CEO, and some of its work unit managers. They told us that they were extremely impressed by the hard work, professionalism and insight demonstrated by each of our teams. They benefited from an outside look (and very cool new equipment mock-ups) at their own operation, and we reinforced and added to our CPI skills.

This morning, after a 5:30 a.m. visit to the enormous and unbelievably bustling Tokyo fish market, our nine-member group from Seattle Children’s gathered to summarize and discuss the key learnings from the trip, to identify the implications for our own hospital operations, and to talk about the next steps for our integrated design process.

We grouped our observations into three important categories: leadership characteristics, CPI tools, and process planning guidelines. These were translated into the beginnings of a high-level plan for the process that we’ll use to design our Phase I hospital expansion. When we get back to Seattle, we’ll engage others to help us complete the data gathering and standard work for our first integrated design workshop, which will take place in February 2009. At least three other related events will be spread throughout the year.

In Japan, we’ve worked side-by-side with people from at least seven counties and have, at times, been challenged by the cultural differences represented in the workshop. We’ve noted how much the experience was strengthened by being away from what we know well, but have also observed how much of our CPI knowledge transcends borders and industries. We also can’t help but see how our host country, a densely-populated, natural-resource scarce, highly-industrialized island nation, functions so well using anthropological standard work, visual cues, and shared goals. We can’t wait to get home and continue planning a facility that will enable Seattle Children’s to advance its vision to be the best children’s hospital anywhere.

—Todd Johnson
Vice President, Facilities

Hello again from Japan.

It’s Thursday morning and our team is heading into the third and final day of factory work.

We all know quite a bit more about gas meters than we did three days ago when we arrived in this large, modern factory. We’ve been impressed by the cleanliness and orderliness of the facility, and have enjoyed the hospitality of the plant’s staff. There are several of the company’s managers in our workshop and they’ve been very helpful in describing current processes, setting up demonstrations, and getting simulation materials.

After a brief familiarization on Tuesday morning, we headed for the factory floor to observe the operators, measure cycle times (which varied from a few seconds on one line to hours on another), and develop ideas for improvement. Each team member produced at least seven ideas, basing them on concepts from nature. For example, in an operation that involved removing paint from a casing, the team referred to sandstorms and the grinding movement of a glacier. With idea forms grouped conceptually, a ranking took placed based on established criteria such as cost, quality, improvements in safety, and capital required to implement the improvement measures. Then off we went to simulate.

The teams used prodigious amounts of cardboard, duct tape, used soft drink bottles, and a few items found in the factory to create a vision of new equipment and production methods. Standard work sheets were developed for the revised processes, which we will test tomorrow (Thursday) morning. Some of our colleagues from the plant stayed late last night producing prototypical carts and other equipment to assist us in this testing. After observing several cycles of the proposed new processes in the redesigned space, we’ll prepare implementation plans for each of the three lines. Our hosts tell us that they want to develop many of the good concepts that have come out of our work here.

Our 1-½ hour bus rides back to our hotel gave the Children’s team some time to reflect on what we’ve seen and how the concepts can be applied to creating a new facility that supports our mission to become the best children’s hospital. We applied some standard tools to the debriefing sessions and recorded some key observations, including:

• Having accurate data about our current processes is essential to improving them.

• Our work begins with process improvement. We can’t build a new facility based on bad processes.

• Even in standardized processes we find variation. We must go to the site of care and observe to get a deep understanding of the work.

• Time is the shadow of motion. Every movement adds time to a process; if it does not add value it should be reduced or eliminated.

• Sometimes simple tools are the best. It’s easy to leap to an IT solution or to buy an expensive piece of equipment but sometimes neither is necessary.

• Simulation, based on the real process, is very powerful in helping avoid problems with the future-state design.

• Building flexibility into the facility is essential because demand and process will change over time.

Tomorrow, our teams will formally present a summary of our work to our sensei and the factory managers. After celebratory lunch and ceremony, we’ll head back to Tokyo where the team from Seattle Children’s will draw together more of our learning and continue translating them to guide our improvement work and phase one project design. We’ll make one more blog entry before we head back to our families and Seattle Children’s on Sunday.

—Todd Johnson

Greetings from Nasu-Shiobara, Japan!

Our Seattle Children’s Hospital team of ten, along with kaizen leaders from Virginia Mason, Park Nicollet Health Systems in Minneapolis, Boeing, and Sun Chemical (EU) arrived on Sunday. We travelled by train and bus to this beautiful resort area 1½ hours northeast of Tokyo that is popular with Japanese seniors and families. It’s an excellent location for learning more CPI tools, because there are few diversions from our studies (except perhaps the acclaimed mineral baths), conducted by three sensei from Shingijutsu Consulting.

Yesterday was dedicated to refreshing old kaizen skills and learning more about 3P, the Production Preparation Process that is a relied-upon planning technique at Toyota and will be used as we at Children’s plan our new hospital addition.

3P was created to generate innovative ideas and new, efficient processes for the design of a new facility. It looks at “hardware” like buildings, machines and equipment, as well as the “software” of standardized work, process flow, built-in quality, and logistics. As with our rapid process improvement events, 3P is based on some established tools and follows a pre-determined order, although idea-generation and innovation are cultivated. The process involves first establishing a complete understanding of the current state by determining essential functions and mapping the flows. The key words, or targets, are sketched, relying on concepts from nature and are then grouped by concepts. Seven ideas for solutions are presented by each team member, then narrowed to a few promising design concepts. Prototypes are created quickly and cheaply, often out of cardboard, and then refined using PDCA cycles. Finally, an implementation plan is developed; it must include the essential “what, by whom, and by when?” information.

During our learning day, the sensei reminded us of the fundamentals of this work. It’s important to remember them as we begin our important facility design work at Seattle Children’s. Some key concepts include:

• Without standard work in place, there is no foundation for improvement. We must know our volumes, our lead times and our cycle times and standardize our work to keep in takt time.

• Everyone must understand and agree upon the need for improvement. We must uncover waste, unevenness, and unreasonableness in our operations.

• We need to identify the problems in our “old house”. We can avoid them as we build our “new house”.

• In our redesigned spaces, flow must be visible. We must design for flexibility, extendibility, and rapid changeover.

To practice our newly acquired skills, we’ll travel tomorrow (Tuesday) to the nearby town of Shirakawa, home of the Yamatake Company division that produces and re-manufactures several types of gas meters. We’ll be divided into three mixed teams (comprised of members of all of the participating American, EU-based, and Japanese companies) and will be led by our sensei, Mr. Iwata, Mr. Koide, and Mr.Shuno.

Each team has been given an assignment and has been asked to complete specific tools (such as the time observation and percent load charts, the spaghetti chart, the fishbone diagram, and the process-at-a-glance form) to give an accurate picture of the current state. Each team has also been given an improvement target.

Team one was asked to remove or relocate impediments to flow and staffing flexibility, like machines or conveyor belts that break up the line. The second group was requested to design an ergonomically-sensitive conveyance system that transports large, heavy meters without workers needing to lift or transfer the product. The third team was asked to redesign a line so that the company could easily flex its staff up and down to meet takt time with wildly varying order volume.

We’ll spend the next three days on the factory floor and will give a formal report on our progress on Friday. We’re excited about the learning opportunities, and are constantly discussing the application of the techniques as we seek to design buildings that take the waste and defects out of our processes. We know that we’ll return home with many ideas to help improve quality, patient satisfaction and staff engagement, delivery, cost, and safety.

We’ll report back as the week progresses.

I’m off to Japan and my first trip with Seattle Children’s to study integrated facility design and planning methods from the Toyota Motor Company - one of the world’s experts. We will be focused on bringing back insights and learnings that will help us plan Children’s anticipated hospital expansion and facilities for the future.

Our first stop is Tokyo. We’ll be building on our knowledge of continuous performance improvement methods. I’ll write more in a few days to share insights during our trip!

—-Todd Johnson

Vice President, Facilities

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