Lean Government
EPA Office of the Chief Financial Officer
Corrective Action Tracking
Kaizen Event Case Study
Summary
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.
Results
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
mentality).
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
Corrective
Action Plan
(CAP)
accepted by
OIG
Responsible
Office enters
CAP into
CATS
ORIM receives
CAP & enters
into the OIG's
system
(MATS)
Responsible
office "fixes it"
and provides
updates in
CATS at least
once a month
Office
Director
certifies
completion of
one or more
Corrective
Actions
ORIM
prepares an
audit
certification
letter based
on Office
Director
input
ORIM closes
the
Corrective
Action in the
MATS
DONE
Audit is closed
out in MATS
after all OCFO
Corrective
Actions are
completed/
certified
Internal Controls (A-123 assessment) Corrective Action Tracking Process
Exception log
from internal
controls
assessor
ORIM
receives copy
of final CAP
Responsible
office enters
CAP into
CATS
Responsible
office "fixes it"
and provides
updates into
CATS at least
once a month.
Each Office
Director's
annual
assurance letter
contains
certification of
one or more
Corrective
Actions
DONE
EPA Senior
Leadership Council
agrees to close
Corrective Action
-------
Implementation
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
Information:
Valerie Green, EPA OCFO, (202) 564-6642, green.valerie@epa.gov
Jamie Burnett, EPA NCEI, (202) 566-2305, burnett.jamie@epa.gov
http://www.epa.gov/lean/leangovernment.htm
United States
Environmental Protection
Agency
Office of Policy,
Economics and Innovation
(1807T)
June 2009
EPA-100-F-09-038
------- |