Sunday, September 7, 2014

Lean Six Sigma in Healthcare World: Successful or Not?

Lean Six Sigma in Healthcare World: Successful or Not?

Lean Six Sigma concept comes from hybridizing the manufacturing/production lean concept that identifies and eliminates processes/waste (DOWNTIME) that has no value to the end customer with six sigma policy seeking approaches that can reduce variance and inefficiency in an organization.  DOWNTIME in Healthcare industry corresponds to issues such as overproduction, defects, non-utilized talent, transportation or inventory, extra processing or waiting. While Lean six sigma model has been applied successfully in many different industries, its value in healthcare set up is not clearly studied or understood. The article titled “Decoding the DNA of TPS” from HBR talks about the value of successful process implementation of lean methodology to reap its benefits not the just the methodologies alone. I find this topic interesting because even though the improvement and change management initiatives tools and methodologies are existent for a considerably longer period yet the healthcare system is a long way from attaining their goals in terms of cost and quality. Healthcare industry has long been crying for help to improve quality while reducing cost of care.  Every year US alone spends around 18% of GDP ($3trillion in 2010) more than any other country and still ranks the last among the similar countries in terms of mortality. Inability to eliminate waste or DOWNTIME is one of the main reason for high rising costs, which was 1/3 ($1.2 trillion) of the healthcare spending.

Here are some of the facts about the US healthcare system:
1)   $765,000,000,000, or 30% of all U.S. healthcare costs, each year is wasted in issues such as medical billing fraud, unnecessary services, inefficiently delivered services, and excessive administration costs.
2)    Up to 400,000 people are killed each year due to preventable medical errors.
3)    33% of hospital patients suffer some form of preventable harm during their hospital stay.
4)   Critical care patients each experience nearly 2 medical errors per day.  The main reason for the errors was significant communication failure between clinicians.
5)   58% of clinicians felt unsafe about speaking up about a problem they observed or were unable to get others to listen.
6)   92% of U.S. physicians admitted to making some medical decisions based on avoiding lawsuits, as opposed to the best interest of their patients.
The mentioned above are just tip of the facts about the growing US healthcare system’s iceberg issues. I strongly believe that the implementation of the lean six-sigma concepts/models will help to reduce the WASTE; errors and avoidable medical cost. Lean six-sigma could be practiced in both provider and payor system in the healthcare industry as a strategy to cut costs, increase capacity and improve quality.

Lean Six Sigma Introduction:
Lean six-sigma, being complex in nature, requires huge commitment and management support to bring performance improvement and change management. Lean and Six-sigma focus on reducing the waste but require different strategies. Still, Many organizations believe that mixture of both the methodologies bring success in a complex organizational process improvement.

Attributes of Six Sigma
Attributes of Lean
Strong, data-driven orientation
Data not always necessary
Strong project management framework, "DMAIC" = Define, Measure, Analyze, Improve & Control
More intuitive, loose framework based on "Current State" vs. "Future State"
Focus on variation in process 
Focus on value stream analysis
Aim is to eliminate defects
Aim is to eliminate waste
Goal is improved quality at lower cost 
Goal is increased speed and efficiency

Healthcare industries should follow the first rule of Toyota’s Production System, which mentions to specify the sequence, content, timing, and outcome to its greater extent. For example, while working at UPMC during internship I observed many departments within UPMC system whose staff did not know how to trouble shoot or whom to contact if there is a problem and how much time will it take for the assigned person to response back. So here, the first rule could help the system to establish a specific point of contact person in times of emergency and help the department to develop standardized protocols in issues that occur frequently. It is quite surprising to see that some of the departments follow the same old protocols over million times even if it is error prone and management notices it only if the damage (or WASTE as per LEAN) is very large.

As mentioned in HBR article “Decoding DNA of TPS”, rules creates an organization with a nested organizational structure, rather like traditional Russian dolls that come one inside the other. Following rules/protocols can improve the healthcare system to investigate the flow of problems to its lowest possible level by constantly soliciting the medical staff to act and react evidence based and protocol based thereby improving their own work. Healthcare system can deploy the lean six sigma performance improvement tool by following the rules:

1)   Staff trained in both Lean and Six Sigma concepts
2)   Establish ROI expectations from portfolio of projects
3)   Sponsor training for senior management team
4)   Create Executive Leadership Awareness
5)   Visibility across enterprise for program and its achievements
6)   Implement formal handoff from project leader to process owner
7)   Continue running control charts on all completed projects
8)   Implement specification limits that identify if performance has regressed
9)   Communicate expectations across the departments.
10)                  Expand Lean Sigma Infrastructure

It is important for the management teams to include the frontline staff because they have greater knowledge of the routine process workflow. It is necessary to involve personnel whose routine work would be affected by the change of process. Creating leaders across the teams will help to attain regular meetings that keep the project running while removing the barriers if any. Running control charts described as “the voice of customer in this case patient” in HBR article titled “Managing quality with Process Control” will help in the quality improvement projects. Patient is the end customer and should be the number one priority hence obtaining regular feedbacks and satisfaction surveys could help with these change strategies. Developing organizational competency for innovation by training a dedicated force of Lean Six sigma program leaders could support the clinical and administrative projects with successful deployment strategies to meet the organizational quality and goals.

Lean six sigma has also proved helpful in many other DOWNTIME areas such as reducing waiting times, booking rooms for patients, reducing medical errors, redundancy in work flow yet it still raises the question why the methodologies are not implemented everywhere and why the implementation has not yet brought down the cost of healthcare with improved the quality and safety of patients.

This topic also incites interesting questions:
1)   What is the reason that hospitals and insurance industries are still incapable of meeting the demands of patients in terms of cost and quality?
2)   What are the governmental policies that are obstructing the healthcare system to fulfill its goals?
3)   What policies are really damaging the patient physician relationship?
4)   What is the reason that physicians are not able to use their clinical knowledge completely and ethically to reduce cost and improve safety of the patients?
5)   What is the reason behind the overprotective medical practice, unnecessary lab tests orders and redundancy in the work flow?
6)   Why is still US spending the most on healthcare system?
7)   What are the factors or policies that are raising the cost of healthcare?
8)   What are the impacts of new healthcare reform on the quality of healthcare? Does it improve, decline or stays same?




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