Kaizen: A Method of Process Improvement in the Emergency Department Gregory H. Jacobson, MD, Nicole Streiff McCoin, MD, Richard Lescallette, Stephan Russ, MD, MPH, and Corey M. Slovis, MD Abstract Introduction: Recent position statements from health care organizations have placed a strong emphasis on continuous quality improvement (CQI). CQI finds many of its roots in kaizen, which emphasizes small, low-cost, low-risk improvements. Based on the successful Kaizen Programs at organizations such as Toyota, the authors thought the emergency department (ED) would be an ideal environment to benefit from such a program. Objectives: The authors sought to create a CQI program using a suggestion-based model that did not require a large time commitment, was easy to implement, and had the potential to empower all physi- cians in the department. It would not take the place of other improvement efforts, but instead augment them. The hypothesis was that such a program would foster sustainable engagement of emergency phy- sicians in system improvement efforts and lead to a continuous stream of low-cost implementable sys- tem improvement interventions. Methods: A CQI program was created for the physician staff of the Department of Emergency Medicine at Vanderbilt University Medical Center, focusing on a suggestion-based model using kaizen philosophy. Lectures teaching kaizen philosophy were presented. Over the past 4 years, a methodology was devel- oped utilizing a Web-based application, the Kaizen Tracker, which aids in the submission and implemen- tation of suggestions that are called kaizen initiatives (KIs). The characteristics of the KIs submitted, details regarding resident and faculty participation, and the effectiveness of the Kaizen Tracker were retrospectively reviewed. Results: There were 169, 105, and 101 KIs placed in the postimplementation calendar years 2006, 2007, and 2008, respectively. Seventy-six percent of KIs submitted thus far have identified a ������process prob- lem.������ Fifty-three percent of KIs submitted have led to operational changes within the ED. Ninety-three percent of the resident physicians entered at least one KI, and 73% of these residents submitted more than one KI. Sixty-nine percent of the attendings entered at least one KI, and 89% of these attendings submitted more than one KI. Conclusions: Over the past 4 years, the Kaizen Program at Vanderbilt has been widely and frequently used within the ED. It has resulted in over 400 changes in our adult ED system and has met the chal- lenge of using CQI to drive ED improvements. There are limitations to this study, including the fact that its impact on patient outcomes remains unknown. However, this Kaizen Program may be an excellent tool for other departments to assist with quality improvement and should be studied with a multicenter prospective approach. ACADEMIC EMERGENCY MEDICINE 2009 16:1341���1349 �� 2009 by the Society for Academic Emergency Medicine Keywords: core competencies, CQI, quality, kaizen R ecent position statements from health care orga- nizations place a strong emphasis on continuous quality improvement (CQI).1���6 Emergency departments (EDs) face unparalleled challenges in today���s health care system and are an ideal environment to benefit from CQI. However, EDs, like many health care entities, struggle to find ways to successfully imple- ment CQI programs that involve every physician mem- ber of their staff.7���12 CQI finds many of its roots in �� 2009 by the Society for Academic Emergency Medicine ISSN 1069-6563 doi: 10.1111/j.1553-2712.2009.00580.x PII ISSN 1069-6563583 1341 From the Department of Emergency Medicine, Vanderbilt Uni- versity Medical Center (GHJ, NSM, RL, SR, CMS), Nashville, TN. Received December 22, 2008 revisions received April 21, June 5, and July 8, 2009 accepted July 13, 2009. Address for correspondence and reprints: Corey M. Slovis, MD e-mail: corey.slovis@vanderbilt.edu.

kaizen, a Japanese business philosophy built on the core principle of continual improvement. Kaizen emphasizes small, low-cost, low-risk improvements that can be easily implemented. It is geared to the everyday worker and lower management, to continually improve his or her own workplace. Innovation, as opposed to kaizen, is intended for upper management and executive use to address large systemic problems with wide sweeping change. Kaizen does not take the place of innovation or large-scale changes, but instead is intended to be exe- cuted along side of them.13 Based on the successful nature of kaizen-type pro- grams at organizations such as Toyota, we believed that it could be utilized to actively involve every phy- sician member of our adult ED in quality improve- ment. To increase our chances of creating a truly successful program, we sought a system that was easy to use, did not require a large time commitment, and allowed every physician involved to experience ownership in the ED���s operations. Suggestion sys- tems, which are of the utmost importance in kaizen implementation, have these characteristics. They empower each individual involved to point out prob- lems, as well as suggest and often implement solu- tions. In the ideal system, every suggestion would receive a response, every success would be publicly acknowledged, and a large percentage of faculty and residents would use it. We sought to create a CQI program that would be easy to implement, was sustainable, and would empower every physician in our adult ED. The pro- gram would teach residents and faculty a method of quality improvement that they could easily use in their day-to-day work. We wanted every member of the physician staff to have a voice in his or her work- place. The system was not intended to halt other improvement efforts, but instead to add another layer of improvement in our department. We hypothesized that implementation of a CQI-minded suggestion sys- tem would contribute to a culture of continual improvement as measured by a sustained flow of CQI process���generated system changes being imple- mented. METHODS Study Design This was a retrospective review of details regarding the CQI initiative that were submitted from May 1, 2005, through December 31, 2008. This study was exempted by the Vanderbilt University Medical Center���s Institu- tional Review Board due to its retrospective nature and the removal of all staff and patient identifiers from the data collection sheet prior to analysis. Study Setting and Population This study was conducted in the Vanderbilt University Medical Center Adult ED, which has an annual volume of approximately 55,000 patients and is the region���s only Level 1 trauma center. Vanderbilt University Medi- cal Center is the home of a three-year PGY 1���3 emer- gency medicine (EM) residency, currently with 33 EM residents and 38 faculty. Study Protocol Phase I (Pretracker). Masaaki Imai���s book Kaizen: The Key to Japan���s Competitive Success served as the educational foundation for our CQI program, which we refer to as the Kaizen Program.13 In two 40-minute lectures, we taught the history and theory of kaizen by distilling it into 13 principles most applicable to the ED setting (Table 1). We initially focused our educational efforts on the residents and focused abbreviated ver- sions were presented approximately 2 months later to faculty physicians. Our Kaizen Program was constructed such that any physician could submit an idea at any time during his or her shift. To facilitate this, we built a Web page titled the Kaizen Portal and placed a link on every work station desktop, as well as on our ED���s homepage (Figure 1). This allowed a resident or faculty physician to submit a kaizen-minded idea, concern, or observa- tion, which we called a kaizen initiative (KI Table 2). Once the KI was submitted, an e-mail was generated to key ED administrators. We encouraged physicians to use the Kaizen Portal to identify areas in need of improvement and, if possible, offer solutions. However, the Kaizen Portal led to many duplicate e-mails to key ED administrators. This original system lacked a well- organized manner of assigning KIs to specific adminis- trators and staff and lacked an efficient method of following the course of the KIs. As a result, no new KIs were submitted in the fall of 2005 until we built the Kaizen Tracker. The pretracker phase of our Kaizen Program took place over a 4-month period from May 1, 2005, to August 31, 2005. Phase II (Tracker Phase). We designed and built a Web-based application titled the Kaizen Tracker to solve the inefficiency and disorganization of the e-mail��� based system (Figure 2). It allows the ED chair to assign staff to specific KIs, set a due date, and categorize each KI into predetermined categories such as ������equipment,������ ������pharmacy,������ or ������radiology.������ The Tracker also indicates whether the KI is active, deferred, or completed and Table 1 Kaizen Principles ��� Continually improve ��� No idea is too small ��� Identify, report, and solve individual problems ��� Focus change on common sense, low-cost, and low-risk improvements, not major innovations ��� Collect, verify, and analyze data to enact change ��� A major source of quality defects is problems in the process ��� Decreasing variability in the process is vital to improving quality ��� Identify and decrease non���value-added steps ��� Every interaction is between a customer and a supplier ��� Empower the worker to enact change ��� All ideas are addressed and responded to in some way ��� Decrease waste ��� Address the work place with good housekeeping discipline *Adapted from Masaaki Imai���s book Kaizen: The Key to Japan���s Competitive Success.13 1342 Jacobson et al. ��� KAIZEN PROCESS IMPROVEMENT IN THE ED