Better Together

The concepts of Lean and Six Sigma have been going strong in the manufacturing divisions of a various industries for some time. Now they’re being used in tandem in healthcare. James Levett gives EHM the lowdown.

“For any quality system to be effective or to work in a healthcare setting, you clearly need leadership that will support it and help make resources available to get things done”
-James Levett

Lean and Six Sigma – you may have heard the buzzwords, but do you know what they mean? James Levett, Chair of the American Society for Quality’s Healthcare Division, does. “Six Sigma was used initially by Motorola and was then popularized by General Electric in the 1990s,” He explains. “It is very much focused on reducing variation in products that are developed and produced, so it streamlines processes and reduces variation, making you produce a high quality product or output. It has been brought into service industries, including healthcare, more and more over the last 10 years.

“Lean comes out of the production system model that has been used for many years at Toyota, and has also evolved into other service industries over the last 10 or 15 years. It’s extremely popular now in healthcare as well, because it has a general focus on emphasizing waste reduction and streamlining processes in organizations. It’s complementary in a sense to Six Sigma. Lean is making things more streamlined and reducing waste; Six Sigma is more looking at a process in detail to reduce variation and output. They both have strengths that complement each other and over the years what’s happened is that a lot of organizations are starting to use some of both of those methodologies to apply to their businesses, and this is true of healthcare organizations as well.”

This is where the current trend towards Lean Six Sigma comes in – an amalgamation of the best parts of both systems. Levett agrees that this is exactly what’s happened. Levett points out that many organizations start with Lean, because it requires less extensive training than Six Sigma does. This was borne out in the ASQ’s recent national benchmarking survey on the use of Lean and Six Sigma in hospitals, which showed that the median investment for Lean was $25,000, and it was $96,000 for Six Sigma. “Starting Lean is a little bit easier and a little bit less costly for organizations,” Levett says. “But again, an organization that’s serious about doing these kinds of things will often employ both principles.”

Life or death
One of the main aims of both systems is the avoidance of defects. In car manufacturing or electronics, this might mean something as relatively minor as a dented panel or a component that doesn’t work, but in healthcare a defect can have life or death consequences.

“Both of these methodologies allow healthcare providers to implement or start to make changes within processes and policies and procedures that make mistakes less frequent,” Levett says. “In other words, they make the care delivery safer and more reliable. I would say that that’s a major focus for healthcare providers now, the idea of patient safety and reducing errors.”

The ASQ’s survey was aimed at determining how many hospitals are doing just that. The association is heavily involved with both Lean and Six Sigma, even offering a Six Sigma certification. “We were aware within our division that there was a lot going on in hospitals who are interested in improving quality and that they were using these concepts,” Levett underlines. “As we discussed it more and more, we realized that we had heard a lot of commentary over the last few years, but we didn’t know for sure who was doing what, so we decided that we would take a survey to see what was actually going on in the market. We surveyed 77 hospitals and looked to see what they were doing, if they were using Lean or Six Sigma and which areas they were using them in.

“We found that about 53 percent of hospitals had some level of using Lean. Not necessarily full deployment but some level of using it, and 42 percent had some level of Six Sigma deployment. It was a little more popular to use Lean but probably not statistically different. We found they were using them in the clinical setting, in which both were used: hospitals that used Lean and Six Sigma used them most often in the operating room and the emergency room.

“With Lean, 61 percent of hospitals were using it in surgery and 60 percent were using them in the emergency room. For Six Sigma, the emergency room was 72 percent and the operating room was 66 percent. The percentage probably isn’t as important, but the idea is that hospitals using both Lean and Six Sigma tended to use those methods in the operating room areas. Those are high volume areas and certainly surgery is a risky procedure overall. In other words, there’s a lot of opportunity for error and it doesn’t surprise me really that the hospitals would have used the methods in those areas.

“I would point out that there were some areas in which they were used in the hospitals as well, which were not just clinical but more ancillary or support service areas, and those areas included admissions and discharge and radiology and imaging. Both Lean and Six Sigma were used for admissions/discharge and radiology or radiology/imaging, which again are areas where you have a lot of things going on, people coming in and going out of the hospital for admissions and discharge, and then radiology has lots of images done every day.”

It makes sense that hospitals would start to use Lean and Six Sigma in these high-volume areas where potentially life-threatening or costly errors could be made. Levett admits that if he’d had to guess ahead of time, where the two systems would be used, those are the areas he would have chosen

Money problems
Another question the survey asked was, if a hospital was not using either method, why not? Levett says the biggest reason given was a lack of resources. “The other reasons were that they didn’t have enough information to use them or deploy them, and the third was that leadership buy-in was lacking. The point there that I would like to emphasize is that for any quality system to be effective or to work in a healthcare setting, you clearly need leadership that’s behind it and that will support it and help make resources available to get things done. That’s true for any organization, not just healthcare.”

If lack of money is a major barrier to implementation, this begs the question of what’s stopping management from buying into these processes that can help reduce costs and even save lives in the long run? The obvious answer is that it requires an upfront investment that many not always be easy to justify in the short term.

“There are data that would suggest savings are accrued,” Levett says. “You do save money when you institute these systems, and there is data out there on both Lean and Six Sigma for healthcare. We didn’t ask that question specifically in the survey, but I expect there will be a lot more information coming out in the next few years around this.”

So money remains a major issue when implementing Lean or Six Sigma in a hospital setting. What are some of the other challenges involved? Levett points out that there is also staff time involved: “The nurses, doctors or other staff that are involved with it have to spend time working with a team to accomplish these things to bring this methodology forward, which also takes money. Staff time is expensive and without a balance sheet that’s real strong, if a hospital is struggling a little bit on the margin, then those resources may not be there. You could certainly make the argument that if you’re going to save money in the long run, it’s a great thing to do. I think as more evidence is accumulated to support the use of these methods in healthcare, it will become more popular, as people are convinced that it’s the right thing to do and it will save them money.

“They’ll be wanting to spend the money upfront because they got positive return on investment in a sense. The other point is that if the leadership of the organization isn’t behind it, then what happens is you might start a little project here or there but it doesn’t go anywhere. The successful organizations that have used these techniques have had major culture shifts. They’ve brought, let’s say Lean, for example, right into the culture and used it on a daily basis so that everybody was involved.

“The same goes for companies like General Electric that have used the Six Sigma systems. I believe that having it as an essential and integral part of your culture is key and that, of course, presupposes buy-in at the top. The leadership of the organization has to make that happen.”

Time challenge
Levett points out that bringing in these new processes also takes time. “It doesn’t happen in a month. It might take two, three, five years. So it’s a major commitment to a methodology and to a system of quality, but it is starting to show payoff in organizations that have used it.”

As with most new initiatives, it tends to be the bigger hospitals with more money and resources who are the earliest adopters. Levett says that although some small hospitals are using Lean and Six Sigma, it does tend to be the bigger systems that are currently at the forefront of implementation.

In terms of the future, Levett foresees Lean and Six Sigma beginning to spread even more widely within the healthcare sector. “Quality is clearly at the top of the list of concerns of interest to healthcare leaders. We’re all measuring more things than we used to. We’re reporting more quality metrics, and I think that this idea of using quality methods in a sophisticated way, in a way that becomes part of your culture is important, and organizations that have used it have been very successful. ThedaCare, for instance, in Wisconsin is a very successful organization that’s used Lean. The Virginia Mason Clinic in Seattle is another one.

“As more organizations get into it, publish information and talk about it, you’ll see more of it used and I think that’s good. It’s the right thing to do, and ASQ is out there trying to support organizations and help them get the best from Lean and Six Sigma for their own advantage and that of their patients”.

James Levett is Chair of the American Society for Quality’s Healthcare Division and Chief Medical Officer for the Physician’s Clinic of Iowa.

American Society for Quality

The American Society for Quality (ASQ) is the world's largest authority on quality. With more than 100,000 individual and organizational members, this professional association advances learning, quality improvement and knowledge exchange to improve business results, and to create better workplaces and communities.

The ASQ has been at the forefront of the quality movement for almost 60 years. Headquartered in Milwaukee, the association traces its beginnings to the end of World War II, as quality experts and manufacturers sought ways to sustain the many quality-improvement techniques used during wartime.

Today manufacturing remains a core of the ASQ’s activities, but ASQ it has established itself as a champion of quality in education, healthcare, the service sector and government.

The ASQ also offers technologies, concepts, tools and training to quality professionals, quality practitioners and consumers. Globally, it has formed relationships with other nonprofit organizations that have comparable missions and principles.

ASQ members have informed and advised Congress, government agencies, state legislatures and other groups and individuals on quality-related topics. The ASQ’s healthcare division has about 3500 members.

Lean

Lean manufacturing is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination.

Working from the perspective of the customer who consumes a product or service, ‘value’ is defined as any action or process that a customer would be willing to pay for. Lean is centered around creating more value with less work.

Lean manufacturing is a generic process management philosophy derived mostly from the Toyota Production System (TPS). It is renowned for its focus on reduction of the original Toyota seven wastes in order to improve overall customer value.

Lean is a variation on the theme of efficiency based on optimizing flow; it is an example of the recurring human tendency toward increasing efficiency, decreasing waste and using empirical methods to decide what matters, rather than uncritically accepting pre-existing ideas.

Six Sigma

Six Sigma is a business management strategy, initially implemented by Motorola, that today enjoys widespread application in many sectors of industry.

Six Sigma was originally developed as a set of practices designed to improve manufacturing processes and eliminate defects, but its application was subsequently extended to other types of business processes as well. In Six Sigma, a defect is defined as anything that could lead to customer dissatisfaction

It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization, using a system of ‘belts’ similar to that employed in martial arts, who are experts in these methods.

Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified financial targets (cost reduction or profit increase).