Process Improvement

There are many ideas, often competing with one another, for improving our healthcare system. There are also many pressures bearing on every healthcare administration, each pushing or pulling its decision-making process in different directions. New laws, such as Obamacare, government oversight, penalties, complex billing systems, shifting and nebulous rules and regulations, insurance interests, competition, financial strains, competing interests within the hospital community, and many other factors come in to play. And at the center of it all, hopefully, is the drive to deliver world-class care to patients.

But when an administration weighs every argument and option, how should it act? Many hospitals make a decision to improve some process or other or reorganize itself for efficiency or for better care outcomes, only to fail once the carefully championed, budgeted, and managed project hits the hospital floor. Hospital processes, people, and infrastructure are notoriously entrenched and difficult to reform. When starting this improvement journey, the system must not go at this haphazardly. The improvement methodologies should be structured and consistent throughout the healthcare organization. Methodologies can be singular or blended, that is, Six Sigma, Lean, Lean Six Sigma. Oft times when either of these are used by themselves, changes are not sustainable, resulting in the expenditure of resources without return and Leadership and front-line staff are left with a bad taste in their mouths toward Change.

The methodology we have found to result in sustainable change is Lean Six Sigma. This methodology is based not only on data but includes buy-in and involvement of front-line staff and Leadership all the way up to the CEO. This involvement results in ownership of the change by both front-line team members and those leading the system. The tools of Lean are easily taught and used by System Leaders and Front Line. When plans for change are developed and implemented by Front Line there is a greater chance for sustainability. The advantage of combining Lean Methodologies with Six-Sigma is timeliness and speed. Where projects using only Six-Sigma methodologies may take upward to 6-12 months to put a pilot in place, the addition of Lean results in analysis, piloting, and implementing change in as short a time as 4-6 weeks.

This book has focused on the Hospital Emergency Department and related units. Our ideas are those that we know, we have put many of them into practice, or otherwise been involved in their development. The ideas in this book are mostly all tested, in that they have been put into practice in hospitals and have been shown to be successful for the most part. We have witnessed both success and failure in this realm and have learned that the two outcomes are often separated by the thinnest of margins. Hospitals that consider and address the following points will be far more likely to succeed in any initiative than those that fail to do so. Just look at today’s prevalence of scatter-bed observation units. There is little evidence to suggest that this approach is better, either for patients or for the hospital. But it is the way we have always done things.

Therefore, we would advise that any administration considering any of our recommended initiatives, or any other for that matter, should first ensure that the following considerations are discussed and dealt with. In our experience, failure to do so can jeopardize success. Any project, in order to succeed, must consider the following:

Project Focus: Everyone must understand the goal of the project. What is the driving force behind it? It must have at its center the care of the patient. Will it impact strategic metrics for the organization? Is it aligned with organizational priorities? There should be no questions left standing before any project can be expected to succeed.

Data: Getting accurate baseline data is absolutely essential to any process improvement. Understanding the current metric that you wish to impact and having the ability to obtain that metric in a consistent and valid fashion is of utmost importance. Without this information, the project’s value will be unknown, its faults will potentially go unnoticed, rather than being quickly spotted and addressed, and its detractors will go unanswered.

Leadership: Developing a team of people to manage the project is crucial. The optimal team size is around five people. Team members may have sub-teams, but the leadership needs to be small and focused. Success generally only occurs if one high level C-suite member is driving meetings and holding all team members accountable for results. Countless projects fall victim to poor communication, distraction, mission fatigue, and lack of accountability, all of which is addressed with a strong leadership team.

Timeline: Further focus on leadership and accountability is a solid timeline that helps keep a project on track. There should be a published schedule for meetings, along with monitoring of baseline metrics such as, current process analysis, development of improved process redesign and implementation and monitoring of the process redesigned. Project completion times will vary, but many in our experience take around 6 months depending on the project’s complexity.

Scaling: Organizations tend to want projects implemented system wide and usually in very short time frames. But complex processes within healthcare take time to reinvent and implement—and sometimes require a bit of tinkering in practice. Many successful projects use a single unit as a guinea pig, of sorts, working out bugs and establishing best practices first. Then, the project can more easily be scaled to other units, eventually achieving the goal of overall sustainable organizational change, but with less risk of an overall organizational failure.

Celebration: It will take a great deal of hard work and dedication to achieve success—and it’s important that everyone involved is recognized for their effort, especially when a project has proven to be successful. This is not only a boost for morale and good publicity for a success but helps encourage participation and expectations of success for future projects.

Below are two examples of actual projects that we have been involved with. Both projects are highly typical of almost any hospital system’s effort to improve, and both could have easily failed (one certainly did). But they are both good examples of what can go wrong and right in any project.