Lean  Government
                      EPA Office of the Chief Financial Officer
                               Corrective Action Tracking
                                Kaizen  Event Case Study

In December 2008, EPA's Office of the Chief Financial Officer (OCFO) conducted the Agency's first completely
internal Lean kaizen event. Ateam of OCFO managers and staff examined the office's internal process for tracking
and closing corrective actions. Corrective actions are developed as the result of findings from independent audits or
self assessments (known as A-123 reviews). For tracking purposes, the corrective actions from audit and A-123
reviews have slightly different reporting requirements which led to separate processes when identifying results.
During the kaizen event, the process was scrutinized from the point at which an approved corrective action plan is in
place until the individual corrective action is completed. The existing process was not standard, required a large
amount of staff time, involved duplication of effort, and could not easily provide summary reports for management.

The week-long event focused on clarifying the corrective action tracking process, developing a standard format for
corrective action plans, clarifying the corrective action close-out process, and codifying all process steps into a
standard operating procedure. The event dramatically improved efficiency by eliminating non-value added process
steps, resulting in a more transparent process with increased data accessibility and improved customer satisfaction.

Audit Corrective Action Tracking Process
    86% reduction in number of handoffs (from 92
     to 13)
    68% reduction in time to process an Office of
     Inspector General Action
     (from 324 hours to 104 hours)
    62% reduction in total number of steps (from
A-123 Corrective Action Tracking Process
    74% reduction in number of handoffs (from 31
     to 8)
    46% reduction in time to process an A-123
     Action (from 185 hours to 100 hours)
    63% reduction in total number of steps (from
     8 to 3)
Scope of the Lean Project

Project Scope: EPA Internal Corrective Action Tracking Processes (OIG & A-123)

Goals of the Lean Event

  Reduce missed milestones by 100% (e.g., no missed corrective actions).
      Results: The team developed a spreadsheet tool to support the new process and increase transparency. Af-
      ter 120 days, offices still have some missed milestones, but the number is decreasing due to regular man-
      agement discussions and heightened awareness and transparency of the update process.

  Reduce rework and duplication by 75% (e.g., reduce the status-check phone calls, e-mails, and fire-drill
       Results: The first cycle involved training people on the new process and tool. After 120 days, qualitative data
       indicate that this measure has been met.  Each office's key contact enters information into the Corrective
       Action Tracking System (CATS) regularly, and it is the first place staff and managers visit to learn about the
       status of a corrective action.

  Reduce status update time by 50% (e.g., create one central place for data).
       Results: The first cycle involved training people on the new process and tool. After 120 days, qualitative data
       indicates that this measure has been met. Each office key contact uses CATS for data entry.
                                    Figure 2: Future State Map
                                                         Future  State
                                                        OIG Corrective Action Tracking Process
                                    Figure i: Current State Map
Process Changes

During the kaizen event,
participants developed "current
state" and "future state" maps of
the process. While creating the
current state map (see Figure i),
OCFO participants saw clearly how
individual roles fit into the entire
process and began to understand
the need for a more efficient
exchange of information.

The future state map (see Figure 2)
helped participants visualize an
ideal method for tracking corrective
actions efficiently while continuing
to meet work requirements. After
the completion of the future state
map, participants began drafting
new procedures and  a new
spreadsheet tool for  tracking
corrective actions that would take
the process for tracking these
actions several steps closerto the
ideal future state map.

The biggest changes in the new
process included:

     Development of a centralized
     spreadsheet tool on its own shared computer drive for inputting status on corrective actions.
     Adoption of a policy and standard operating procedure to input data in the central spreadsheet.
     The new ability (as a result of the spreadsheet) to create reports for senior management on a regular schedule.
Final OCFO
Action Plan
accepted by

Office enters
CAP into
ORIM receives
CAP & enters
into the OIG's

office "fixes it"
and provides
updates in
CATS at least
once a month
completion of
one or more
prepares an
letter based
on Office

ORIM closes
Action in the
Audit is closed
out in MATS
after all OCFO
Actions are

Internal Controls (A-123 assessment) Corrective Action Tracking Process

Exception log
from internal

receives copy
of final CAP

office enters
CAP into

office "fixes it"
and provides
updates into
CATS at least
once a month.

Each Office
assurance letter
certification of
one or more

EPA Senior
Leadership Council
agrees to close
Corrective Action


  Since the event, participants have been working to implement the new spreadsheet tracking tool and update the
  process. This new tool was released in January 2009 for testing and refinement. Staff and managers are pleased that
  the new process eliminates numerous unnecessary status checks and handoffs that caused delays, and are also glad
  to have summary reports available for review. Continued follow-up by the Lean facilitator, team leader, event
  participants, and OCFO management has been integral to maintaining a focused effort to implement the new
  corrective action tracking process and fulfill the goals of the project.

  The lean event team is currently in the process of creating a Lotus Notes database to enable even more streamlined
  updates, and expects the database to be live and in use in summer 2009.
          For More
Valerie Green, EPA OCFO, (202) 564-6642, green.valerie@epa.gov
Jamie Burnett, EPA NCEI,  (202) 566-2305, burnett.jamie@epa.gov
United States
Environmental Protection
            Office of Policy,
            Economics and Innovation
     June 2009