Six Sigma in Healthcare:
A Discussion
Professor George S. Easton
(c) 2015 George S. Easton
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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.
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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.
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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.”
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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.
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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.
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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.
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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.
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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).
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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).
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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).
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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.
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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.
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See Excel File
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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.
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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.
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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.
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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.
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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)
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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)
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Project Examples (con’t)
• 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?)
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Project Examples (con’t)
• 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.
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Example Financial Results in HC
Facility Type
Improvement
Opportunity
Regional Medical
Patient LOS in ED
Center in the
and admit bed delay,
Southeast
reducing diverts
Healthcare Delivery Increase throughput
System in California and generate
incremental revenue
opportunities
Large Metropolitan
Reduce number of
Hospital System
inpatient transfers
(defect — any
patient transferred
more than once)
Health System in
Bed availability (3
Midwest
projects)
Renowned Academic Improved throughput
Medical Center in
and workflow for
California
PACS, MR, CT,
CR/Ortho
Result
$1 million in
documented gains
$8.4m in
documented gains
75% reduction in
inpatient transfers;
$2m annual cost
savings
$1.86 million in
documented gains
$4 million dollars in
documented gains
Source: http://psqh.com/janfeb05/sixsigma.html
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Comment
• I cannot possibly teach you in depth about
Six Sigma in 2 hours.
• Many things are being glossed over or
skipped.
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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.
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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.
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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))
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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.
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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
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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.
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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.
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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”
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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.
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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.)
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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.
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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.
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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)
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How This Works (con’t)
• 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
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How This Works (con’t)
• 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.
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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.
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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.
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Note:
• To systematically improve in any kind of a
fundamental way, you have to have
consistency.
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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!)
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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.
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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.)
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