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The complexity of hospital operations and the ongoing need to ensure safe and high-quality patient care continues to present challenges for hospital managers and administrators. Kaizen events (KEs) offer opportunities to address some of the ongoing challenges in managing performance within a complex hospital environment. Kaizen events - a type of improvement project - have been utilized in healthcare as a mechanism to apply improvement tools to reduce waste, reduce non-value-added activity, and improve quality of patient care. A Kaizen event is a focused and structured improvement project utilizing a dedicated cross-functional team to address a targeted process or work area with specific improvement objectives in an accelerated timeframe. A critical issue for hospital is understanding the key factors that support and ensure the effective use of KEs in hospital settings to achieve the outcomes and benefits that impact both operations and the stakeholders of care. A preliminary assessment of a systematic literature review - a rigorous research method that evaluates and synthesizes the literature - was used to answer the primary research question: What are the main success factors of Kaizen events in hospital settings? Qualitative analysis was performed to extract, synthesize, and characterize the most frequently-reported success factors for KEs. Additional analyses were conducted to assess the strength of association between factors. This synthesis of knowledge is useful for practitioners for increasing understanding and improving the effectiveness and success of KEs in hospitals.
Abstract
The complexity of hospital operations and the ongoing need to ensure safe and high-quality patient care continues to present challenges for hospital managers and administrators. Kaizen events (KEs) offer opportunities to address some of the ongoing challenges in managing performance within a complex hospital environment. Kaizen events - a type of improvement project - have been utilized in healthcare as a mechanism to apply improvement tools to reduce waste, reduce non-value-added activity, and improve quality of patient care. A Kaizen event is a focused and structured improvement project utilizing a dedicated cross-functional team to address a targeted process or work area with specific improvement objectives in an accelerated timeframe. A critical issue for hospital is understanding the key factors that support and ensure the effective use of KEs in hospital settings to achieve the outcomes and benefits that impact both operations and the stakeholders of care. A preliminary assessment of a systematic literature review - a rigorous research method that evaluates and synthesizes the literature - was used to answer the primary research question: What are the main success factors of Kaizen events in hospital settings? Qualitative analysis was performed to extract, synthesize, and characterize the most frequently-reported success factors for KEs. Additional analyses were conducted to assess the strength of association between factors. This synthesis of knowledge is useful for practitioners for increasing understanding and improving the effectiveness and success of KEs in hospitals.
Keywords
Kaizen Events, Hospitals, Continuous Improvement, Success Factors
Introduction
Healthcare operations can be adversely affected by a multitude of problems that can undermine patient care delivery. The need to address ongoing challenges in a timely and efficient manner remains crucial. Hospital leaders must be proactive and responsive to mitigate the burden of complexity and compartmentalization. Management must continuously pursue Healthcare Continuous Improvement (HCI) to minimize problems or deficiencies that can negatively impact operations and the quality of care that patients receive. Inspired by the application of Kaizen events (KEs) in other sectors, such as manufacturing and service industries, KEs have been more recently utilized within healthcare to bring about meaningful changes (Holden & Hackbart, 2012). Kaizen events have been successfully applied to healthcare operations as a continuous improvement mechanism (Sankoff et al., 2013; Cowen & Joseph, 2016). Due to the potential impact of this type of improvement initiative within hospitals, it remains advantageous to be examined. A KE is defined as a "focused and structured improvement project utilizing a dedicated cross-functional team to address a targeted process or work area with specific improvement objectives in an accelerated timeframe" (Farris et al., 2009, p.1). KEs have great potential to achieve breakthrough improvements and can support hospitals' continued efforts to improve processes and bring about critical changes that ensure efficient care processes and highquality patient care (Skeldon et al., 2014; Biffl et al., 2011). Understanding what contributes to success for KEs in hospitals will help leadership to implement key components that accrue high benefit with minimal resistance and waste in the KE effort. Hence, this paper seeks primarily to identify the main success factors for KEs in hospitals. The following sections discuss additional background information about KEs, describe the SLR methodology used along with justification for further analysis on KE success factors, present and discuss research findings, and summarize insights from this work along with recommendations for KEs within hospitals and future work.
Background
A Kaizen event is commonly referred to as a Rapid Improvement Event (RIE) in hospitals. This type of improvement project usually facilitates a larger change initiative, often associated with Lean Production and transformation to providing value in healthcare (Meyer, 2010). Important design characteristics of KE use in hospitals, such as goals and objectives, target work area/process, event duration, team size, team cross-functionality, event pre-work and planning, and event format, are summarized by Harry (2020). These characteristics are essential to the planning and implementation of KEs. KEs in hospitals also utilize key improvement tools to support and execute an improvement effort Harry (2020). The most frequently-reported improvement tools used by KEs in hospitals documented within the literature are process mapping and value stream mapping, which can be categorized as general process improvement tools (Harry, 2020). The time duration for a KE in general is usually between 3-5 days (Natale et al., 2014). However, due to constraints on employee time and commitment, variations to this event duration have been evaluated and adopted in healthcare settings to realize benefits and accommodate employee needs (Culcuoglu et al., 2012; Natale et al., 2014). Typically for a KE, frontline workers and other key employees and individuals directly involved with the targeted area are assembled to problem solve and develop low-cost, expeditious beneficial solutions for implementation (Meyer, 2010). In hospitals, KEs have achieved improvements in patient flow management, healthcare operations, and patient experience (Athawale et al., 2013; Martin et al., 2009; Kostango & Jagiela, 2010). In addition, KEs in hospitals have also achieved substantial social system benefits (Bortolotti et al., 2018); KE team members have reported a sense of satisfaction due to a positive experience on the KE and due to successful outcomes for work process improvement and patient care (Hummer & Daccarett, 2009). One important challenge for KEs in hospitals is the sustainability of process changes made and the resulting outcomes (Skeldon et al., 2014). After a KE has been executed and initial improvements obtained, the KE effort can be undermined due to a lack of follow-up activities that cause outcomes and benefits to regress (Gilfillan et al., 2016). There are essential practices that must occur to ensure the success of a KE, and in addition, other important considerations that should be leveraged to achieve beneficial results. Documented within the literature, there is a common recognition and acknowledgement for ensuring management support throughout the duration of the project to achieve successful outcomes (Holden & Hackbart, 2012; Bortolotti et al., 2018). In addition, proper KE planning, team design characteristics, and activities to sustain improvements are also necessary for success (Sankoff et al., 2013; Cowen & Joseph, 2016).This type of improvement initiative has the potential to achieve rapid beneficial results with limited capital and should be continuously pursued. Hence, determining what factors most contribute to KE success is critical to ensure longevity in utilization. The next section describes the Systematic Literature Review (SLR) methodology used in this work.
Methodology
A previous Systematic Literature Review (SLR) of KEs in hospitals was conducted and is described in Harry (2020). This SLR resulted in a set of 38 papers used for analysis of the published literature on KEs in hospitals, including the identification of key KE design characteristics (such as team size and event duration), improvement tools utilized, and outcomes achieved. As described in this paper, this same paper set was also analyzed further to identify success factors reported in the literature. The SLR approach is described in more detail in Harry (2020) and is briefly summarized here.
Using an SLR approach enables a rigorous and comprehensive assessment of the literature due to the process applied for identifying and screening papers. The PRISMA model (Moher et al., 2009) was adapted for the SLR used in this work, with four overall stages. The main stages of the SLR were: 1) Identification of relevant papers, 2) Screening of papers based on title and abstract review, 3) determining Eligibility of papers based on full text review, and 4) identifying the final set of Included papers after applying exclusion criteria. The initial search strategy included the search concepts and search terms synonymous for Kaizen Events and Hospitals. A detailed search string was formulated and queried within the ProQuest platform that resulted in 796 papers considered for screening and selection. A final set of 38 papers was ultimately attained after excluding papers that did not meet the pre-defined exclusion criteria. Exclusion criteria were developed based on unique aspects related to the focus on KEs, the desired focus on KEs conducted in a hospital setting, and specific characteristics unique to KEs as a type of improvement project (such as event duration). More detail about the SLR methodology and its application that resulted in the 38 papers analyzed in this work is provided in Harry (2020). The reference list for the 38 papers can be provided upon request.
Although the initial search protocol did not include a unique search concept or terms explicitly related to success factors, a prevalent theme found in 29 of the 38 papers (76%) was mention of key factors relating to KE success - whether factors viewed to enable success or factors that represent obstacles inhibiting success. Based on this prevalence, a more detailed analysis to identify the success factors KEs within hospitals, as reflected in the published literature, was conducted, and is described in this paper. Leveraging past studies on success factors for continuous improvement projects in hospitals and for performance measurement implementation efforts, a set of success factor "codes" with predefined operational definitions was adapted and applied to extract success factors from the 29 papers having reference to success factors - see Exhibit 1 (Gonzalez Aleu & Van Aken, 2016; Keathley, 2016). These findings, focused on the identification of success factors, their relative frequency, and potential inter-relationships, are discussed next.
Findings
Forty-six unique success factors were extracted from the 29 papers mentioning success factors in some fashion. On average, each paper identified 5.8 factors, and this ranged from 2 to 12. These factors are shown in Exhibit 2, along with the relative overall frequency of success factors reported. Names for success factors were defined neutrally from the papers analyzed, regardless of whether they were framed initially in a given paper as a positive or negative characteristic, and in accordance with the success factor framework applied in this work. A success factor in a given paper was only counted once, even if it was mentioned multiple times in the paper (such as in the results and in the conclusions). The most frequently-reported success factor was General management support, mentioned in eleven of the 29 papers (38%), with the next most frequent being Team commitment to change (mentioned in nine papers), as well as Stakeholder representation, Structured methodology, and Organizational culture (each mentioned in eight papers). Of the four success factor categories shown in Exhibit 1, it is interesting to note that these five most frequentlyreported factors span three of the categories: Team design, Organization, and KE process. Factors relating to Task design, the fourth category, were also identified in the paper set but just not as frequently compared to other factors. This finding demonstrates that, in general, the factors reported by authors in the published literature highlight the need for a holistic approach to designing and implementing KEs. As an additional overall point, it is important to note that the KE success factors reported in the literature include those that more generally relate to any type of organizational change initiative (such as General management support, Organizational culture, and Training), those that relate to improvement teams in general (such as Structured methodology, Team communication and coordination, and Goal clarity), and those that may be more unique to KEs as a form of improvement team (such as KE planning, Crossfunctionality, and Follow-up activities). This finding highlights the importance for KE practitioners to utilize the research and findings in the literature on organizational change in general, on improvement teams in general, and on KEs specifically.
Several points can be made relating to the specific factors reported the most frequently in the literature. General management support, identified in the highest number of papers, is not only commonly identified as an important factor in many types of change initiatives, as noted above, but has also been found in previous KE research to be a significant predictor of social system outcomes (i.e., team member attitude) for KEs (Farris at al., 2009). Having strong support from upper management ensures that KE coordinators, facilitators, leaders, and team members are supported throughout the KE effort - with information, resources, guidance, and feedback. Upper management often has the responsibility of giving final approval for significant process changes as well as allocating resources to improvement projects. If management support is perceived to be lacking, this can negatively impact KE outcomes, due to lack of autonomy for a KE team to fully explore process changes, lack of resources (financial and otherwise), lack of clarity on the KE goals, etc. Lower-level managers and employees serving on a KE team may not fully and promptly obtain the assistance needed to successfully execute the KE project. Team commitment to change was the next most frequently-reported success factor in the literature and has also been found in prior KE research to be a significant predictor of the social system outcome of increasing improvement capabilities of KE team members (Farris et al., 2009). The significance of this factor implies that KE team members must place high importance on their participation on the KE team and their creative contributions to changes identified by the team. Within a hospital setting, this factor may even be more critical, given that other responsibilities and priorities may compete for KE team members' time and focus in a dynamic work context with customers/patients having varying needs and at variable times. Employees must exhibit a strong conviction to the cause of continuous improvement and see value in engaging in such activities such that positively benefit employees, their work, and patient care. Next, Stakeholder representation is reported numerous times within the paper set analyzed which means that for a hospital setting, it is significant to include all key individuals who will benefit from improvement efforts of focus by a KE. This goes beyond the typical inclusion of employees involved in the targeted work area/process but extends to individuals such as patients, healthcare partners, and improvement consultants. These latter individuals can provide meaningful and relevant insights into improving patient care along with unveiling critical considerations that could be overlooked in this type of complex environment. Structured methodology refers to the KE team using a systematic improvement methodology. Given the accelerated timeframe for a KE - 3-5 days vs. several months as in a traditional continuous process improvement team - it is not surprising that a well-defined improvement methodology has been found to contribute to success. The prevalence of Organizational culture as a success factor reported in the literature indicates that, within a hospital organization, senior leaders must guide the organization into adopting shared core values, policies, and practices aligned with continuous improvement. Cultivating a workplace culture of continuous improvement can help employees to readily accept and participate in organizational improvement endeavors.
The next set of most frequently-reported factors were KE planning, Team member acceptance, Crossfunctionality, Training, and Frontline leadership engagement. Proactive planning for a KE is a critical component for ensuring success, particularly given the accelerated format for KEs; KE planning has also been found to be a significant predictor for KE goal achievement (Farris, 2006). This is particularly applicable to hospital environments, which tend to have high variability within their system. The targeted problem or area to be improved must be deemed necessary or critical for KE team members to invest their time, skills, and energy in the KE project. If there is any perception of a lack of a sense of urgency for improvement or value in engaging in the KE team, the KE project may be met with hesitation and resistance throughout the process. Next, although many hospitals are striving for integrative care, most often, hospital departments exist in silos, which may make it difficult to increase standardization of practices, which is often an aim in KEs. Bringing together frontline workers and other functionally diverse employees who interact with the targeted area/problem on the KE team is necessary to overcome this challenge and to ensure the delivery of optimal care. Training in improvement skills is essential to equipping with knowledge and skills related to the specific improvement tools to be applied within the KE, given that these will not typically be tools needed in the everyday activities of KE team members. Lastly, the ability for clinicians, nurse managers, and other frontline leaders to fully engage throughout the duration of a KE is critical since the solutions and protocols developed, and those that are eventually implemented during or after a KE, most often directly impact their line of work. For example, clinicians, although more limited in discretionary time for improvement activities, should not minimize any part of the KE process but should strive to engage in all steps to ensure their contributions are seen, heard, and incorporated into the delivery of optimal patient care. Other factors identified in the paper set are not discussed here but are shown in Exhibit 2. In addition, success factors identified only once in the paper set (Goal alignment, Project duration, Target area routineness, Target area commitment to change, Team engagement, Team size, KE priority, Financial resources, General resource support, Software/IT, Performance evaluation/review, Support from KE program, Action orientation, Planning for institutionalization, Stakeholder communication, and KE technical documentation) are not shown in Exhibit 2 for conciseness.
In addition to documenting the relative frequency of each success factor reported in the literature, as shown in Exhibit 2, it was also beneficial to document how authors framed these factors from a more granular perspective - that is, whether each factor was described from a positive, negative, or neutral orientation. This representation can be seen in Exhibit 3. For clarity, factors were labeled as enablers (positive), barriers (negative), or neutral (neither), respectively, in Exhibit 3. Most factors were identified in a positive orientation in the paper set. This can be attributed to KE practitioners experience in conducting KEs and their awareness of key enablers or other supporting factors that achieve success and the need to emphasize those as high-leverage components to be addressed in implementing KEs. However, multiple factors were expressed in a negative orientation, highlighting the unfavorable impact that can happen, if not addressed, or lacking, prior to or during the KE. It was interesting to see that Team member time was reported in every instance from a negative orientation. In addition, the factor Follow-up activities was mostly referenced from a negative orientation, highlighting the negative impact these factors can have on KEs if they are not managed properly or are not prioritized within a hospital setting. As shown in the exhibit, there were a minimal number of occurrences of success factors framed from a neutral perspective.
A co-occurrence analysis for the success factors was conducted to examine the relationship between success factors. Social network analysis using NodeXL was utilized to create the co-occurrence network and evaluate other graph metric data associated with the relationship of the success factors. Co-occurrence analyses are useful in identifying relationships and the extent of the relationships between items (i.e., the strength of association between factors) (Hansen et al. 2010). The frequency of the success factors was represented by the size of the vertices and displayed in the network as black circular nodes labeled by the unique success factor name. Edges shown represent a co-occurrence between two success factors within a given paper, and the edge width represents the co-occurrence frequency between those two factors. Exhibit 4 represents the complete co-occurrence network, showing the relationships that exists among all 46 factors. Considering the complete co-occurrence network, the network shows that many of the factors have distinguishable pairs. This indicates that success factors indeed have some identifiable relationships that can help hospital KE practitioners holistically strategize when undertaking a KE. Identifying the factors that have strong relationships can help KE coordinators to best recognize them and determine how to integrate these factors into the KE process to maximize efforts and outcomes.
Graph metrics output retrieved from NodeXL recorded that there were 394 unique edges, indicating 394 unique relationship pairs between success factors. The highest co-occurrence was six, with Organizational culture and Team commitment to change identified together most frequently. This may indicate that an organization engrained with a strong commitment to continuous improvement can have a strong influence on their employees' desire and commitment to improve to achieve best results. This is pertinent within a hospital setting where there can exist a high level of compartmentalization and diverse specialty practices. When hospital leadership and executives can reinforce a culture that values and pursues healthcare continuous improvement, then employees will readily understand the significance and necessity of their commitment to improvement change efforts to enhance hospital operations and care. Employees that are typically siloed by departments can have a strong motivation to collaborate with their peers to achieve ongoing success in streamlining processes and administering quality patient care. Furthermore, based on observations from the condensed network diagram generated, for the case where n is greater than or equal to 3 (see Exhibit 5), the following interesting insights are seen. It was observed that the unique pairs both consisting of 5 cooccurrences, General management support linked with Cross-functionality, and similarly, Structured methodology linked with Cross-functionality, are closely associated. For the former case, this can mean that if higher level leadership is keen in aiding KE projects, this can enable timely employee permissions and approvals without or with minimal resistance to the assembly of the functionally-diverse group of employees whose participation is essential to the success of hospital KE initiatives. From the latter's perspective, using a systematic approach for a KE can in some ways legitimize the need and act of bringing together functionally diverse employees to accomplish KE goals and objectives. A structured format can provide foresight and preparedness. Employees can anticipate activities, time commitments, and expectations to plan accordingly. Although not typically expected, the above-mentioned associations, along with the absence of other typically expected strong connections such as Organizational culture and General management support can possibly be attributed to contextual factors or based on authors' reporting strategy for results and findings. Another frequently-occurring co-occurrence was with General management support and Training. This highlights a common observation throughout the literature for General management support as a necessary factor in achieving success. Having the support from higher level managers ensures the provisioning of critical items needed for KE success. When higher level managers are strongly onboard for KE improvement projects, then essential and beneficial resources for the KE to be successful will be met. Resources are more readily allocated to accomplish the educational and skill building needs that support KEs. The results from the co-occurrence analyses are also interesting in that they demonstrate that factors do not exist in isolation but rather are interconnected, potentially influencing each other to achieve or maximize the overall effect desired.
Conclusions and Future Work
This work contributes a preliminary identification of the important success factors documented in the literature (as reflected in the paper set analyzed here) and a preliminary examination of the interconnectedness of these factors. These findings can provide important insights into key relationships that help support successful Kaizen events in hospitals. Determining KE success factors can help hospital management and continuous improvement coordinators to best strategize to achieve and ensure the success of a KE. This is most necessary in hospital environments that require fast-paced solutions with minimal complications. One key action is to ensure that management is supportive of the KE which will more than likely direct their efforts to its success. Moreover, due to the time commitment involved in participating in a KE and the constraints on employee time, it would be beneficial for those directly planning a KE to exercise caution and astute judgment when determining the duration and scheduling the KE. Although the SLR described in this work did not explicitly include a search concept for success factors in the search strategy, clearly a prevalent theme in the paper set analyzed was the identification of success factors, whether framed as enablers or barriers/obstacles. Thus, this work provides a preliminary identification of the most frequently-reported success factors for KEs in hospitals, with future work potentially crafting a search strategy explicitly designed to identify papers focusing on success factors. This type of future work should enable an even more robust and comprehensive set of success factors. Future work should also seek to empirically investigate the influence of success factors on KE outcomes and success in this type of organizational environment.
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