Lean and Six Sigma

Transforming healthcare

Jason Lebsack, Manager Six Sigma Nebraska Medical Center, USA.

Lean and Six Sigma are powerful tools that help in making the leadership strong.

How will the application of Lean and Six Sigma help in improving the quality of services?

I think it will help in a number of ways. Our organisation looks at the benefits in terms of what we call the 'Three Goods' that can come out of a project: improved clinical safety and outcomes for patient, improved efficiency and effectiveness of what you do at the hospital operation and improved work satisfaction among employees. Overall, we are looking at making the jobs easier for staff and for the physicians who practice in the hospital.

How have Lean and Six Sigma jelled when it comes to the healthcare sector?

I think they have jelled very well. In our organisation, for example, we feel like without having Lean as a part of our whole improvement tool kit, we would have not been able to identify many of the improvement opportunities that we have over the last five years within our project work. Because of the access to data and because of the variations that exist in some process and some complexity, a lot of time can be saved by just using Lean thinking in terms of looking at the flow of people, material and information in a process. You can find a wealth of opportunities right there. We've seen from colleagues around the country some more benefits that ensue through the application of Lean in combination with Six Sigma.

Do you think Six Sigma has caught on in healthcare the way it has in other service sector industries?

I think so. Especially in last seven years, Six Sigma has caught on substantially within healthcare. The wave of implementation of Six Sigma Lean, has facilitated by the To Err is Human report that happened in late 90s. I think the difference that I see in the way it has caught on in the healthcare vs. any other industry is that their primary focus is on Revenue, Cost reduction and other financially-focussed kind of measures and metrics. In healthcare, you see that spectrum that I talked about before i.e. using it to sometimes work on projects that have no apparent financial benefit that can be clearly attached to it-perhaps, improved patient safety and patient care clinical outcomes are the most common results. I think it has caught up in a different way for a different reason and continues to be used and applied in different ways in many projects with great success.

What about the other parts of the world?

The other parts of the world, I am not so sure. I think that I have a glimpse of it from the conferences that are being held in Europe and other places. I know from the folks who taught us, GE Healthcare, the consulting firm of General Electrics Healthcare, about the business they are doing in other parts of the world. I've also come across examples in recent months of Lean being applied in a number of hospitals across Canada. So, saying that it is growing in its application would be the best way I can describe it.

It is said that Six Sigma improves any existing business process by constantly reviewing and retuning the process. How easy or difficult is this in healthcare?

Well, I think that in terms of ease or difficulty, one of the things I say is that it's not just about how you can apply the technical aspects of either Lean or Six Sigma. I think, for us the number one issue is the availability of data. A lot of times, when you get into the project, there isn't any data colleted about what ultimately becomes the outcome measure or many times the input measure that you want to look at. The time and energy it takes for the project team to work through to development of the measurement system is quite considerable. Another important point is of ownership and sponsorship; that is, the leaders and their ability to hold accountability for the behavioural changes and process changes that are going to be a part of the improvement plan from a day-to-day and the long-term perspective. What does not help here in healthcare is that there isn't necessarily a strong heritage of having operational measurement as a part of the leadership.

What are the areas to be covered while implementing Six Sigma in healthcare?

There is book by Jim Collins titled Good to Great: Why Some Companies Make the Leap...And Others Don't, that talks about placing 'Who' before 'What'.What he means is that the focus has to be on the people who are going to be doing work and the talent that you have in the organisation to get the task accomplished. In Six Sigma programmes, we have to look at people who are going to be dedicated resources for leading project efforts. The people need to have a unique combination of the ability to think about the technical, analytical and quantitative parts of what goes along with doing quality improvement work and a strong interpersonal skill set. They have to be able to build trust with a group, build team dynamics within the group and build relationships. So, that's the one place I can say the effort must start.

How can hospitals scope and create a project roadmap to run Six Sigma projects?

To begin with, there is a need to get a direction from your senior executives on the most important areas for improvement in the organisation. In other words, where do they want their finite resources within their quality improvement group to focus on? If you know those areas of focus, then it is really about using assessment tools, looking at data, spending time doing some initial investigation and getting some requests or some calls from the leadership to find out not just one project that would be helpful in that area but multiples, if any. And then to be able to run parallel projects within a particular area-like for example in our organisation it would be within our Operating Room-along with multiple belts or having one project getting done and the another one starting immediately and continuing to work in that area to get larger scale improvement. The idea of focussing on an area and having focussed projects to get out the little pieces of the problem is the key.

What could be the time frame for the implementation?

When we were first taught about Six Sigma from GE Healthcare, they talked about a 4-6 months as the time frame for a project to go from beginning and defining phase to getting to an improvement and initiating a hand-off. That is the typical time frame we try to shoot for a good project. At the low end, we've had project where we worked on a 30-60 days time frame. But they tend to be very focussed efforts on a very specific issue. We've had other projects at the maximum that have gone on for 18-24 months to get a particular thing solved. And the thing I would emphasise about this is: it all depends on what you would call a project. Learning from experiences as an organisation is what adopting Six Sigma and Lean is all about. What we thought of as a single project today, we probably think about as three or four or five distinct projects. And so, a piece of advice that I give to folks who are just getting started is to really focus on scoping down your projects to as narrower a topic as you can and think about getting improvements committed in that before going to the next thing, rather than trying to bite off a very huge chunk and feeling kind of defeated because it takes a long time to get all the things in place.

What happens after the implementation?

After you have initially implemented something what you should hope to have done is demonstrate your goal. Once you can demonstrate a goal infirst one or two projects, the key is to continue to build knowledge and skills within the organisation and the ability to lead projects gained by black belts and green belts. Another key is to build in some steps for self-sustainability for teaching and mentoring projects. So, you will be working to develop those who are the internal master black belts so that you don't have to rely upon external consulting to keep going. The focus then would be to continue to work all the way down to the staff level to build that skill set. In summary, the answer would be, continue to get the people to understand what it means to apply Six Sigma, and then you just need to continue to work on getting better at how you do it from the stand point of how long your projects take, how well you scope the project and learn from previous project work that you do-both for the improvements to come out of it and the way that you went about doing the project.

Do the benefits outweigh the costs involved in adopting Six Sigma?

You are asking the question to a biased guy. I say, absolutely they do, if you are committed. And this is the big If. If you are committed to applying the tools and principles appropriately, if you are dedicated to the idea that you are going to follow a process, that you are going to use data to drive decisions, that you are going to involve the people who are close to the work to come up with solutions and recommendations for improvements, Then you are going to put in accountability structures to hold people to keep up the improvement that would be made. So, absolutely, the benefits outweigh the cost and you have to look at it in healthcare to be a bigger thing than simply the financial returns that you get.

Considering the importance of the organisation's leadership, could it be a roadblock to the success of a project?

Absolutely. The way I would describe the leadership and its importance is that I would say it is a critical, but not sufficient, component to making all this kind of work successful. What I mean by that is, if you do not have senior executive support, if you do not have them serving as the people to be communicating the importance of quality improvement, as the people who are removing barriers in terms of getting improvement projects moving down the road and to be sponsored, if they are not the folks providing direction in terms of focal areas for where they would like the resources to be deployed, if they are not playing a part in holding people accountable, it will not work. But, when I say it's not sufficient, I say that a strong set of leadership in the absence of having people who are leading the project and most importantly the staff who are engaged and motivated in recognising the rewards of being involved in the actual problem solving. So, you need both pieces of it. But I am yet to see an example of an organisation who is successful in applying either Six Sigma or Lean where they did not have strong leadership.

Could you share with us a real life situation from your experience, where the top management's role was epitomised?

There are several examples. In one of the projects, some of the improvements that had come out were about getting some physical, technological changes and enhancements to the nursing ward. The work was queued up within the various groups of the hospital and wasn't moving along. The sponsor of the project was made aware of that through the concerned black belt and got directly involved in working backwards with the areas responsible and initiated a continued follow-up with them. He got the work queued up and finished in the time frame needed. Project sponsors in a number of situations have had to address leadership concerns in the areas involved. In some cases this has meant making leadership changes.

Author Bio

Jason Lebsack