We were able to see how these ideas were applied in the factory environment. The Yamatake plant we visited today had great quantities of materials, people, and machines in compact but organized, safe, and neat work areas. The overall impression is one of a calm, smooth work flow (e.g. no one yells or seems to be searching frantically for misplaced items).

Differences in culture and language have made us realize the challenges faced by families and children at the hospital. Not understanding the language makes you more aware of gestures and facial expressions. We are learning to communicate through interpreters and have come to appreciate the power of pictures, visual cues, and cartoon signs when struggling to make sense of factory work flow.

Visiting the Toyota Museum and seeing the evolution of the loom in the weaving industry showed how many small incremental changes lead to significant improvement over time. We also saw this today at Yamatake, where they have been doing Continuous Improvement for twenty years, but it was still apparent (even to us) that there were many opportunities still in front of them.

During today's observations, our team noted the importance of inspection. Inspection at every step was integrated into the manufacturing process. Rather than seeing inspection as wasted (or repetitive) time, here it is viewed as an integral part of the process to ensure quality in the long run and to make the detection of an error more timely so there could be on-the-spot training.

We were also struck by the support of the workers on the production line - a person in a role called water strider (we have yet to understand how it came to be called that) was available to each work unit to help workers get what they needed it just when they needed it. There was a true sense of concern for the worker - the ergonomics and tools were designed to avoid wasting a worker's motion, and there was a commitment to not interrupting their work. Visual pictures and graphics were used to describe work processes and make sure work was done the same way every time. This aided in cross-training and ensuring quality.

Specific ideas that could be possible at Children's include using a water strider in the core in the OR (allowing Circulating Nurses to stay in the OR rooms); case cards in the OR could be pictures that more accurately describe the instruments needed (better than words can). Inpatient care plans and discharge criteria could be posted for families (which might make a positive change in the Respect scores for inpatients and help keep the team and family on the same page).

Another learning was about the CPI process itself. Instead of looking at CPI as a monthly event , Yamatake viewed continuous improvement as part of their daily work. One idea for General Surgery would be to have short huddles at the end of clinic to gather ideas for improvement to implement before the next clinic.

It was clear to our team that in order to clearly see the problems and make improvements, you have to first have standard work. This is going to be a big effort across the organization. CPI is much like we envision climbing Mt Fuji would be- much preparation, commitment, and hard work is required, but the effort will be worth it "at the top" for the families and staff at Children's.