Government medical organizations are turning to business process improvement methods forged on the assembly lines of the automotive and electronics industries to fight errors and waste. By spotting and eliminating variations that disrupt health care processes, the techniques are designed to improve patient outcomes — and bottom lines.
Two techniques — Six Sigma and Lean Manufacturing — predominate in the so-called management engineering field.
Six Sigma began as a systematic effort by Motorola in the 1980s to adapt, modernize and institutionalize statistical methods to define the limits of process variations that caused product defects.
Lean Manufacturing, often simply called Lean, evolved from academic studies in the 1980s that aimed to understand why Japanese automakers were outperforming U.S. companies. Lean’s priority is to make the best use of material resources and time by eliminating waste.
“The discovery was there were some plants that were getting half in, twice out,” said Steven Spear, a senior fellow at the Institute for Healthcare Improvement and a senior lecturer at the Massachusetts Institute of Technology.
At first, leaders in the health care field tried to apply those lessons to processes that most closely resembled manufacturing — such as payroll, call centers and inventory — but more recent attention has focused on clinical and lab settings. Practitioners of both disciplines are trained to ensure that every step adds value to the end result.
“I characterize Six Sigma as improving customer satisfaction by eliminating defects,” said JoAnn Klinedinst, senior director of health care information systems at the Healthcare Information and Management Systems Society and a member of its Management Engineering-Process Improvement Task Force. “The whole idea of Lean is to effectively and quickly deliver true value to the customer. Lean equals zero waste; Six Sigma equals zero variation.”
Much of the academic and marketing literature combines the two disciplines in the catchall Lean Six Sigma. But Klinedinst said it is important to maintain a distinction when deciding which to use: “Do they want to reduce waste or do they want to reduce variation?”
However, she said the two approaches have important synergies. “You can have a process that’s inefficient,” she said, such as billing processes that cause patients to be charged for services they didn’t receive. Using Lean techniques to streamline a process can go a long way toward fixing defects in a product or service. At the same time, Six Sigma targets undesirable variations in the process that can lead to faulty results.
DOD likes it Lean
The Defense Department has been using Lean Six Sigma for more than a decade and last year used it as the basis of a departmentwide Continuous Process Improvement initiative. The Army’s health care organization has embraced the effort.
“This is not a pilot program merely at headquarters,” said Col. Gaston “Randy” Randolph, director of strategy and innovation at the Office of the Army Surgeon General and Medical Command (Medcom). “It’s across our organization.”
Medcom launched its management re-engineering project in fall 2005 when it contracted with a Lean Six Sigma consultant to train leaders at headquarters and 11 subordinate commands. The following spring, officers, senior civilian executives and directors at the strategic level received training. By summer 2006, hospital workers were being trained in the discipline.
Randolph said the techniques helped employees troubleshoot long wait times at the appointment call center at Carl R. Darnall Army Medical Center in Fort Hood, Texas, which handles 10,000 calls a week. Callers complained that they sometimes waited half an hour to speak with someone or hung up in frustration.
But an investigation by a Lean Six Sigma team revealed the causes of customer dissatisfaction. “We purchased software that cut our patients off after 25 minutes, and we didn’t even know that,” Randolph said. Another discovery: The longest waits and highest number of caller hang-ups happened first thing in the morning, the result of patients calling as soon as the center opened at 7 a.m. That created an instant backlog of callers while attendants were still making their way to their desks.
Randolph said call attendants on the Lean Six Sigma team came up with their own solution: staggered arrival times. Some employees now come in at 6:30 a.m., which had the added benefit of raising employee morale since some preferred to leave earlier in the afternoon.
“At the end of this five-month project, they reduced mean wait time to 33 seconds,” he said. “That’s a sixfold improvement.”
In another case, Medcom’s Tripler Army Medical Center in Honolulu worked on a Lean Six Sigma project with the local Veterans Affairs Department hospital to fix billing errors that had created an adversarial relationship between employees at the two organizations. A joint team used Six Sigma statistical methods to determine the percentage of bills that had errors and were sent back for corrections or rework.
“In this case, it was a problem of coding,” Randolph said. “Some of our staff [members] weren’t coding the patients in the right way.”
The team’s modifications to the process resulted in savings of $975,000 in the first nine months of 2007.
“Now they have a collaborative relationship, they’ve worked through the process, they’ve improved it together, and now they’re friends rather than adversaries,” Randolph said.
Although Lean and Six Sigma have different twists on management ills, both rely on data analysis. “It’s data-driven decision-making,” Randolph said. “They improve the process based on the data.” He said he hopes to train more Medcom employees in the methodology.
“It’s all about continuous improvement,” he said. “Once you learn these tools, you think about customer processes in a new way. Now I don’t even mow the lawn the same way.”
Quality improvement methods can also enhance the performance of information technology systems. “You don’t want to automate a bad process,” Randolph said.
He cited another Medcom project as an example of how Lean Six Sigma can work the kinks out of a paper-based workflow before IT automates it. Medcom had partnered with the Army’s Physical Disability Agency to perform a Lean Six Sigma analysis of the process the Medical Evaluation Board at Walter Reed Army Medical Center uses to decide if injured soldiers can return to duty or must retire for medical reasons.
“There were all sorts of variations going on in the Medical Evaluation Board packet,” Randolph said. “It would get to the Physical Disability Agency, and they would kick it back because there were errors.”
Patient packets had 38 required documents, and team members were able to cut the number to 18 initially. They are now automating the streamlined process and expect further reductions.
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