Applying Lean Six Sigma in Healthcare

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Applying Lean Six Sigma in
Healthcare
The Mindset, Structure and Toolset for
People-Intensive Processes

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The goal of this session is to
provide participants with the
foundational mindset,
structure, and toolset of
applying Lean Six Sigma to
people-intensive processes
like those in Healthcare.
Session Goal

At the end of this session, you should be able to:
Clearly define quality in Healthcare
Determine opportunities in both Clinical and Nonclinical
Services
Define project opportunities
Describe the concept and importance of controlling
variation
Describe the main goals in each of the DMAIC phases
Session Objectives

Quality Improvement in Healthcare
Topic

Quality starts with the
patient. If you are ill and
need to visit a hospital,
what is your expectation of
that hospital?
What Defines Quality in Healthcare?

The Quality of Health Care in America Committee of the Institute of
Medicine (IOM) conducted an extensive study and published the
findings. In To Err is Human: Building a Safer Health System the
committee determined:
“It is not acceptable for patients to be harmed by the health care
system that is supposed to offer healing and support.”
Quality Starts With Patient Health –
Clinical Services
50,000 – 100,000 people a year die in American hospitals due to medical
errors that could have been prevented.
The report concluded that the errors were not typically the result of
individual recklessness but of faulty systems, processes and conditions that
failed to prevent mistakes.

Reduced time to check-in to hospital
Reduced admission time from
emergency room to floor
Reduced billing errors
Decreased number of times a patient
got the wrong meal
Increased system availability
Quality in Nonclinical Services

Places emphasis on quality measures and improvements
Requires the reporting of sentinel events (major actual or
possible clinical errors)
Emphasizes the use of root-cause analysis to identify and
build permanent corrections to systems and processes
Joint Commission for Accreditation of
Healthcare Organizations
“Mistakes can best be prevented by designing a safer health
system at all levels.” IOM in To Err is Human.

DMAIC Structure in Clinical Services
Topic

DMAIC Brings Structure to This Simple
Equation
Input
Variables
(Xs)
Outputs
(Ys)
Process Variables (Xs)
Process
)X,...,X,f(XY n21

Measure
Performance &
Focus on Critical
Areas
What is DMAIC?
Where’s the PAIN to the
Patient? The Hospital?
80% 20%
Drill Down for
Root Cause
Pull It Out by
the Roots
Monitor & Take
Action If Root
Cause Re-appears
DMAIC is the recipe or methodology for improving existing
processes; it is the backbone of Lean Six Sigma.

Diagnostic
Treatment
Preventative
Define Phase – Define the Problem
Error or delay in diagnosis
Failure to employ indicated tests
Failure to act on results of monitoring or testing
Error in performance of an operation, procedure or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an abnormal test
Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment

Define Phase – Select Project
Operation
Error
Diagnosis
Error
Drug dose
error
Failure to
Test
Lack of
Monitoring
Treatment
Delay
Frequency 15 12 4 4 3 2
0
5
10
15
Frequency
Error Type
Errors Resuling In Patient Death
Diagnosis
Error
Drug dose
error
Failure to
Test
Treatment
Delay
Operation
Error
Lack of
Monitoring
Frequency 47 33 28 25 16 15
0
20
40
Frequency
Error Type
Clinical Services Errors
Prioritize by Impact
Determine Frequency
and Impact of Problem

Business Case – Hospital XYZ reported 40 sentinel events (major
actual or possible clinical errors) in the last 12 months.
Problem Statement: 37% of sentinel events occurred during
patient operations.
Goal Statement: Reduce or eliminate sentinel events during
patient operations by >90%.
Define Phase – Write Focused Project
Charter

Measure Phase – Narrow the Focus
Start by asking questions and
look for the answers in existing or
sampled data.
If you were working on this
project, what would you want to
know about the below problem?
Problem Statement: 37% of sentinel
events occurred during patient
operations.

Measure Phase – What were the types of
surgeries that resulted in sentinel events?
Craniectom
y
Surgical
Ventricular
Restoration
Spinal
Osteomyeli
tis
Coronary
Revasculari
zation
Bladder
Cystectomy
Esophagect
omy
Pancreatec
tomy
Frequency 13 9 6 4 3 3 2
0
2
4
6
8
10
12
Frequency
Surgery Types
Surgery Types of Sentinel Events

Two Common Problems in Fixing Processes or Systems:
1. Solving at the symptom level
2. Tampering with the process
Analyze Phase – Drill Down to the Root
Cause
What will happen if you determine the solution in either
way?

Root Cause Analysis
Topic

Building Cause and Effect Diagram
1. Name the problem or defect. Problem
or Defect
2. Determine the major categories of causes.
3. Brainstorm potential causes under each category.
Material Machine Method
People Environment
Problem
or Defect
Measurement
System

Identifying Potential Root Causes: Think
Deep
1. For most likely causes
identified on the main bones
2. Ask “Why?”
3. Brainstorm potential sub-
causes, and for each sub-
cause identified…
Why ?
Why ?
Why ?
Why ?
Why ?
Repeat
5 times
5-Whys Analysis

The Concept of Variation
Topic

Variation is Reality
Mean CL: 30.48
-2.68
63.65
-7.21
2.79
12.79
22.79
32.79
42.79
52.79
62.79
72.79
82.79
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Individuals-InstallationTime
No two things are exactly alike.
There is variation in every
process/system.
Even things that appear identical
are not.
Too much variation in processes
and systems will lead to errors.
We must understand how much
variation exists and the causes
before we can reduce it.

Common Cause – events
happen sometimes to
everyone – part of the
process (indicates system/
process needs
improvement)
Special Cause – events
only happen sometimes to
some people/processes –
out of the ordinary
Two Causes of Variation
This happens
all the time
Why does this
only happen to
me?

Common Cause Factors Special Cause Factors
Example: Work Commute
When you commute to work – the time it takes varies from day to day. Why?

Understanding Variation
Situation All nurses make this mistake from time
to time.
Only one nurse is making mistakes.
Type of Variation Common Cause Special Cause
AppropriateResponse
Look at all the data and find out why
mistakes are being made (e.g., soiled
cloths are in same type of bin as sterile
ones). Make fundamental process
change (put in different shaped bins).
Look at that one clerk and find out
what is different (e.g., trained on old
system). Address that specific instance
(e.g., train on new system).
InappropriateResponse
Investigate each occurrence of a mistake
and try to change the process so it won’t
happen again.
Train everyone on new system.
“Tampering” – treating Common Cause like
Special Cause – increases process variation,
wastes time trying to investigate and explain
random events, and frustrates workers
Treating Special Cause like Common –
wastes resources and may frustrate
workers
Knowing the factors and the type of cause (Common versus
Special) will determine the action you should take.

Improve Phase – Determine the Solution
and Standardize It
Inconsistent
Processes
Inconsistent
Results
L
People doing whatever it takes
J
Consistent
Predictable
Results
Standard
Processes

Class Discussion
The word standardization usually
provokes feelings and thoughts.
Why might you experience
resistance to process/system
standardization in healthcare?

Control Phase
The goal of the Control Phase is to:
Observation
Cost
24222018161412108642
14
12
10
8
6
4
2
0
_
X=5.84
UCL=12.28
LCL=-0.61
Assure long-term process control
Transfer full process responsibility back to process owner
Close the project

In Summary
The Mindset, Skillset, and Toolset of Lean Six Sigma is not
exclusive to non people-intensive processes.
It will work in determining root causes and solutions of problems
in clinical services. The implementation of identified solutions will
require cultural changes that are driven from the top, but the first
step is to identify the solution.
Patients should not be harmed by the healthcare system that is
supposed to help them, but the solution does not lie in assigning
blame or urging health professionals to be more careful.
It starts with error-proofing systems and processes to avoid
repeat errors. That’s where the DMAIC structure within Lean Six
Sigma fits in.

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