Cultural Background

• Administration

• Health Care

• Program Delivery

• 5 S + 2

One of the first Kaizen we conducted involved our Human Resource (HR) recruitment process. A program manager needs to hire a new employee, and under our original process, a request had to be made to the Executive Director (ED) authorizing the recruitment. After that approval, the recruitment started and the program manager provided information on the requested hire. After all of the required information was given, the ED was given an advertisement to approve. Advertising started, and when a sufficient number of applicants responded, the ED was sent copies of all the applicants and asked to help grade them for suitability to interview. Interviews were then scheduled around the convenience of the interview team. When the hiring decision was made, background and other checks were conducted. Then an offer was signed by the ED and given to the top candidate. Unfortunately, we did not establish baseline data for this process until after the ED delegated the hire decisions to his Division Directors, effectively removing him from the process. After this delegation

occurred, the recruitment was measured to take, on average, 144 days to complete. By then, many of the original candidates had already found employment, and the recruitment had to be repeated. During our Kaizen, we mapped the Value Stream and realized that it took 144 days to complete. When we reviewed the reasons for the delays, we quickly removed over two weeks of delay by creating a Hire Requisition Form containing all of the information required to recruit. Unnecessary approvals were eliminated. Advertisement and an interview strategy were outlined in the form, and grading the applicants was left to a small team based on objective criteria. The pool was limited to three or four candidates and all interviews were conducted within one week. Any member of the interview team unable to make the interviews just missed them.

Use of Lean tools reduced our recruitment process down to 32-33 days, a reduction of 77% of the total process time. We discovered an ability to find and hire great employees before other employers had a chance to make offers.

Billing is a critical part of any health care operation, and at Chugachmiut our billing specialist came into our Kaizen resistant to any analysis. In fact, most employees are resistant because they believe that their work methods and habits are going to be questioned and they have to justify everything they do. It takes a lot of work to convince employees that the past is the past, and what we are interested in is the future. But, in order to get to the future, we need to understand the past, and work to eliminate the waste that exists in the past.

Our VSM of the patient billing cycle was incredibly instructive. When we started the VSM, our employee told us that she needed two more employees, a benefits specialist and another coder. During the improvement idea stage of the Kaizen, she wrote down two improvement ideas as “faster fingers” and “no vacations.” After the future state was mapped, her tune really changed. Her comment—“I can finish the billing in the morning, and have the afternoon available for patient benefits.” How did we get to this result {although we haven’t achieved it yet]?

There were essentially two basic reasons for the huge delays in the patient billing process. The first delay was the batching of patient encounter forms (PEF’s) and Superbills in our village clinics. Four clinics submitted approximately 260 documents at the end of each month. This created an immediate backlog that, when mixed in with existing work from our urban clinic, took a couple of weeks to enter and process. The second delay was the huge volume of rework that had to be done because the PEF’s and Superbills had numerous defects. The employee had to call providers, wait for them

to return her call, research the issue and make the corrections. The solutions proposed were very simple. As an intermediate step, we reduced the batching initially to weekly, and now to daily. In the meantime, our experienced coder left our employ and we have come to understand the need for and benefit of training, which we will discuss later. We also had to deal with health care division resistance to lean improvements. We know the future state holds incredible benefits for us, and we have made considerable progress towards the future state. But, in our experience, any Kaizen can open up other defective processes that contribute to the one you are mapping. That happened to us in our patient billing process. Our Health Records Management software, developed and maintained by the federal government, is archaic and full of waste. It is difficult to learn, maintain and operate on a daily basis. We are currently looking at alternatives. Our coding processes are also complex and we have not adequately trained our staff on how to complete our PEF’s and Superbills with the correct codes. And we understand more fully the benefits of one piece flow.

We are currently requiring each clinic to submit all PEF’s and Superbills at the end of the day, and ultimately when complete after our Electronic Health Record is installed and operational. We are recording our paper inflow and outflow, together with processing time and defect rate for each document, to understand our training needs. We currently dedicate 18.75 hours a day of administrative resources to billing and contract health care processing. Our average daily document flow is 25, which indicates 45 minutes is required for processing each document. We expect to find and eliminate considerable waste in this process.

Chugachmiut operates a language curriculum development program, which is currently in its third and final year. The L&C team was concerned about its ability to meet grant deadlines because its curriculum development process was taking in excess of 140 days for completion of each module. After a mapping session of about 4 hours, the team developed a future state that allowed for completion of each module within 15 days, together with a Gantt chart and assignment of duties for accountability.

Lean encourages transparency and Chugachmiut has installed Process Control Boards for the purpose of promoting

transparency. Each program has defined and outlined the standard work it does. Understanding and mapping standard work lets us understand how to measure it. And measuring it helps us understand how to improve it. In our experience, there are very few non-profits who measure well. There are some who keep track of the number of people they serve, and perhaps the services they provide. And many non-profits keep basic financial measures. But very few keep good performance measures that we can benchmark against have been available to us for the non-profit work we do. There are more in the health care field because of the profit nature of many hospitals and clinics.

At Toyota, a productive workplace is an organized workplace. They use a process the call 5S to order their workplace, which refers to their Sort, Set in order, Shine, Standardize and Sustain. Chugachmiut adds Safety and Security because of its work in health care, social and behavioral services, and in public safety. Safety is there for obvious reasons. Security is added to focus on our confidentiality obligations.

We conducted our first serious 5S + 2 effort in our Port Graham Health Clinic with excellent results. Here is a link to the memorandum, with photos, that I sent to Chugachmiut staff to let them know about the results. We have applied a couple of lessons learned from the 5S + 2 event that might be helpful. Because transportation to our Villages is expensive, we have learned that it pays off in the long run to send and install quality furnishings and equipment. Shipping costs are the same for poor quality items.

Sending a technician to a Village to repair poor quality equipment is waste and to be avoided. We have also learned just how much inventory is necessary for a Village, and instead of carrying year(s) worth, have started to adjust to a two-month inventory. We have also learned about the high cost of storage and the negative consequences of a disorganized workspace. In our Anchorage office, every nook and cranny attracted “stuff.” A Quonset hut rented by Chugachmiut was filled with all kinds of junk stuff. When we cleaned it out, there were old dental chairs, camping gear, and to my horror, personnel records sitting next to a one gallon can of gasoline. Stuff that hadn’t been used in a decade sat in storage. We hauled away pallets full of records that were far beyond any reasonable retention schedule. Storage areas at Chugachmiut now hold only those items that are needed in a six-month period of time. All others are evaluated for need, and discarded if not needed on at least an annual basis.