Six Sigma in Healthcare: A Discussion Professor George S. Easton (c) 2015 George S. Easton1.

Six Sigma in Healthcare:A Discussion

Professor George S. Easton

(c) 2015 George S. Easton 1

The Need: Errors• 1999 Institute of Medicine Report: 44,000

to 98,000 deaths due to preventable medical errors.

• 2013 Study: Lethal harm to 210,000 to 400,00 patients.

• Serious harm is 10 to 20 times more common.

• Third leading cause of death in U.S.


The Need: Waste

• Harvard School of Public Health article: Waste may be 30% of 2.8 trillion healthcare spend. Much is spent on over-treatment.

• Typical company: waste at least 15% to 25% of sales.

• Much rework is never even identified.


Quality In Healthcare

• CMS definition: “The right care for every person every time.”

• IOM definition: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”


Quality in Healthcare Dimensions

1. Appropriateness: Correct treatment given state of knowledge.

2. Availability: Ease of access to appropriate care.

3. Competency: Ability of practitioners and conformance to care standards.

4. Continuity: Coordination among providers; smooth flow of services.


Q in HC Dimensions (con’t)

• Effectiveness: Right care; desired outcome; right things done.

• Efficiency: Economy of resources consumed in delivering desired care/results.

• Prevention/Early Detection: assessment and/or intervention to promote health and prevent disease.


Q in HC Dimensions (con’t)

• Respect and Caring: sensitivity to needs, expectations, differences. Patient involvement in decision-making.

• Safety: Minimize risks to patient and provider. Free from hazard and/or unnecessary risk.

• Timeliness: Care at the most beneficial time. Patient perception of prompt care.


8

What is Six Sigma?

Six Sigma is:• A management system for driving quality

improvement.• The Six Sigma System is parallel to and

outside of the normal day-to-day management structures and procedures.

(c) 2015 George S. Easton

What is Six Sigma? (con’t)

• As a management system it involves:– organizational structures (e.g., teams,

committees)– roles (e.g., green belt, black belt, team leader,

etc.)– processes, methods (the problem-solving

process, experimentation)– analysis techniques and tools (e.g., the quality

tools).(c) 2015 George S. Easton 9

What is Six Sigma? (con’t)

• As a management system it involves (con’t):– principles (management-by-fact)– norms, shared representations, and systems of

meaning (i.e., a culture).


11

Characteristics of Six Sigma

Key characteristics:• Improvement occurs via projects executed

by teams.• Processes are central. Processes are the

focus of the improvement projects.• Improvement is based on a problem solving

framework (DMAIC).

(c) 2015 George S. Easton

Characteristics of Six Sigma (con’t)

• Strong emphasis on metrics (and especially those relating to costs).

• Focus on defect and/or cost reduction and on reduction of variation.

• Increasing emphasis on customer focus.• Driven by internal consultants: black belts• Heavy emphasis on statistical methods and

experiments.(c) 2015 George S. Easton 12

What is Lean?Lean focuses on:• Flow: Value Stream Analysis

– Rhythm: Takt Time– Pull and JIT: Production in response to and “close to”

consumption.• Waste reduction: the 7 wastes.• Organization and cleanliness: The Five S• Error Proofing• Visual Workplace: Andon boards and lights.

(c) 2013 George S Easotn 13

See Excel File


The Six Sigma Belts

• Black Belt: Highly trained process improvement specialist:– The backbone of the system.– Full-time temporary position for 2 to 3 years.– Leads own projects and consults with other

projects.– Goal of 1 per 100 employees.– Completes 5 to 7 projects per year.


The Six Sigma Belts (con’t)

• Green Belt: Trained in process improvement (2 weeks of training). – Part-time involvement (5% to 10% but

recommended goal is 10% to 20%).– Can leads own projects, but usually serves as a

team member.– Goal of at least 2 to 5 green belts per black belt.– Completes 1 or 2 projects per year.


The Six Sigma Belts

• Master Black Belt: Very advanced and experienced black belt:– Full-time position.– Skilled consultant.– Leads own projects, supports black belts in

their role, and consults with other projects.– Goal of 1 per 10 black belts.– Trains and certifies black belts.


The Six Sigma Project

• On average, six months duration.• 4 to 6 team members.• Typical savings of $100,000 to $250,000

per project.• Should generally require little investment.• Project follows a structured team-based

problem solving framework (DMAIC).• Projects should be tracked and archived.


Project Examples

List from http://psqh.com/janfeb05/sixsigma.html

• Reduction in blood stream infections in ICU (six sigma)

• Stroke patient length of stay (lean)• Reduced number of inpatient transfers (six

sigma)


Project Examples (con’t)

• Emergency department patient wait time (lean)

• Improved patient throughput in radiology (lean)

• Reduction in lost films (six sigma)• MR exam scheduling improvement (not

clear)



• Staff recruitment and retention (six sigma)• Operation room case cart accuracy (six

sigma)• Physician (professional fee) billing

accuracy (six sigma)• Appointment backlog for hospital-based

orthopedic clinic (lean?)



• Quality of care and satisfaction of families in newborn ICU (six sigma).

Note: I think the idea of classifying the projects are “lean” or “six sigma” is a bit false.


Example Financial Results in HC


Facility Type Improvement Opportunity

Result

Regional Medical Center in the Southeast

Patient LOS in ED and admit bed delay, reducing diverts

$1 million in documented gains

Healthcare Delivery System in California

Increase throughput and generate incremental revenue opportunities

$8.4m in documented gains

Large Metropolitan Hospital System

Reduce number of inpatient transfers (defect — any patient transferred more than once)

75% reduction in inpatient transfers; $2m annual cost savings

Health System in Midwest

Bed availability (3 projects)

$1.86 million in documented gains

Renowned Academic Medical Center in California

Improved throughput and workflow for PACS, MR, CT, CR/Ortho

$4 million dollars in documented gains

Source: http://psqh.com/janfeb05/sixsigma.html

Comment

• I cannot possibly teach you in depth about Six Sigma in 2 hours.

• Many things are being glossed over or skipped.


Measurement for Improvement

• Accounting measures are generally poor for the purpose of process control and improvement.

• Measures should be in the units of the workplace.

• Measures should emphasize the problems.• Variables measures and upstream measures

are preferred.


Inspection Exercise

• Inspection is the “go to” approach that many people jump to in order to prevent mistakes and ensure quality.

• Healthcare uses inspection constantly.


DMAIC

• DMAIC is a 5 phase problem solving framework.Define (define and justify the project)

Measure (measure the process, collect evidence)

Analyze (form and test hypotheses, improvements)

Improve (implement and validate improvements)

Control (standardize the improvement(s))


DMAIC is Supported by Tools

• Seven basic tools: Pareto charts, histogram, scatter diagram, control chart, check sheet, stratification, cause-and-effect diagram, flow chart.

• New Seven Management Tools: Matrix diagram, affinity diagram, relations diagram, PDPC, arrow diagram, tree diagram.


Tools

• Statistical Process Control• Process capability analysis.• FMEA (Failure Mode and Effects Analysis)• Regression• Designed Experiments.See: http://asq.org/learn-about-quality/quality-tools.html


Problem Solving Frameworks

• Problem solving frameworks are important!• Implement the scientific method which is

HARD.• Guide and discipline the problem-solving.• Force management-by-fact.• Provide shared understanding for

communication.


Problem Solving Frameworks

• Provide a framework for reporting on (and capturing) project results.

• Through experience, develop trust in the results developed by teams using the process.


Root Causes and the 5 Why’s

• A root cause is a true underlying cause of a problem.

• The “5 Why’s” is the idea that you have to ask why five times in order to “drill down” deep enough to get to the true root cause.Search for “five whys example”


Reversible vs. Irreversible

• Improvement can be reversible or irreversible.

• Improvements to equipment are often(?) irreversible.

• Improvement that require changes is human behavior are reversible.

• It is hard to make reversible improvements stick.


Clinical Experience Is Unreliable

• Experts are right most of the time (maybe 80% to 90%) but are wrong far to often (10% to 20%) to be considered reliable.

• Experts often vastly underestimate what is not known.

• Experts inappropriately project knowledge from one context to another (e.g., theoretical knowledge into the workplace.)


Clinical Experience Is Unreliable

• There are many cognitive biases that make conclusions based on clinical experience suspect.

See: http://en.wikipedia.org/wiki/List_of_cognitive_biases

• Experts do not know everything they know at any one point in time.– The attention window is narrow and influenced

by a variety of haphazard factors.


How This Works

• Expert notices patterns in clinical practice.• Expert forms hypotheses

– This is a human trait, we are hypothesis machines.

– Hypothesis formation is influenced by many cognitive biased such as the recency effect or the tendency to try to assign causes to random events.


How This Works (con’t)

• Expert unwittingly seeks evidence that supports the hypothesis and ignores or discounts evidence that does not support the hypothesis (confirmation bias).

• Over time, hypotheses that seem true and are untested become beliefs. (Juran)



• Over more time, “expert” develops a stake in the belief being true. (Juran)

• Expert now resists any attempt to test the belief and may well reject the results of any test.– Waste of time, not necessary



• Beliefs held by groups are often even more entrenched.– The fact that others believe something seems to

humans as evidence that it is true.

• Groups repeat their beliefs over and over again and the more they are repeated, the truer they seem. (repetition matters)

• There is a life lesson here.(c) 2015 George S. Easton 39

Why is Six Sigma Hard in HC

• Six Sigma is hard everywhere.– Like being fit and thin.

• Medicine is complex and getting more so.– Many patients with multiple conditions.

• Large variation in patients.


Structural Barriers

• For hospitals: Who is the customer? Doctors or patients?

• For all HC: Who is the customer? Patients of insurance companies or employers.

• Third party payment: all of the incentives are wrong.

• Physician independence.• Shortages.


Note:

• To systematically improve in any kind of a fundamental way, you have to have consistency.


Cultural Barriers

• Hierarchy (Doctors are gods.)• Physician autonomy (you can’t tell me what

to do).• Role definitions and specialization (not my

job).• Not invented here. Healthcare is different.

(No it’s not!)


Barriers Due to Ways of Thinking

• Failure to understand the limits on the value of clinical experience.

• Failure to recognize value of consistency for improvement.

• Focus on maximizing physician efficiently.• Reliance on batch processing.• Reliance on inspection.


Barriers Due to Thinking (con’t)

• Don’t see processes as a subject for experimentation.

• Someone should do a study and define best practices. That is, waiting for the literature. (This kind of thinking does not occur in industry.)


Six Sigma in Healthcare: A Discussion Professor George S. Easton (c) 2015 George S. Easton1.

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