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Making the case for Lean Six Sigma in the healthcare sector

06/07/2021 11:51 pm

Mon, Jun 07, 2021 Vijaya Sunder M

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The Lean healthcare systems worldwide witnessed a significant evolution in the past two decades by transforming the processes and the behaviors within the healthcare firms. For example, Mayo Clinic in the USA implemented Lean in the early 2000s and achieved higher customer satisfaction among the cancer patients in their chemotherapy department.

Another such example is the National Health Service in the UK, where Lean deployment has improved hospital performance and delivered significant cost savings.

Even in developing economies such as India, Lean implementations have transformed both clinical and non-clinical processes among the hospitals. For example, in 2019, Fortis hospital, India’s second-largest hospital chain, declared that it cut costs by 20 per cent by embarking on Lean deployment.

In an interview with an executive director of the Apollo Hospitals Group, it was mentioned that they have been practicing Lean in their work processes to improve both efficiency and effectiveness.

While Lean implementation in the healthcare sector has provided some success, it had its share of drawbacks.

First, most of the Lean works in healthcare links to the traditional Toyota Production System and have not included the recent developments in Lean.

Second, implementing Lean in hospitals has been a daunting task in many countries, as Lean does not demand a data-driven approach.

Third, several studies emphasized that the leading cause for poor patient care in hospitals is the incorrect selection of Lean projects based on hospital management’s intuition.

Further, in many organizations, Lean has been perceived as an ad-hoc activity without considering its systemic implications. While the Lean literature endorsed several field-based tools like value stream mapping and visual management, it missed recognizing other important continuous improvement (CI) tools like process mapping, control charts, root-cause-analysis, etc.

Importantly, Lean does not address process variation related issues. Finally, the criticism that Lean lacks a project management framework to execute projects has been a concern among practitioners.

Alongside these, the healthcare sector’s inherent challenges like unevenness in healthcare operations, measurement system and quantification challenges, demarking healthcare as a market, defining patient as a customer, have been vague and, in fact, majorly unaddressed. 

With the recent development of Lean Six Sigma, a hybrid method that combines the rapidness of Lean and Six Sigma’s robustness, most of these problems get addressed.

Our research and practice of applying Lean Six Sigma in various healthcare contexts, including out-patient departments, mobile hospitals, pharmacies, healthcare insurance, diagnostic labs, intensive care, and in-patient admits, have convincingly endorsed Lean Six Sigma’s fitness for providing high-quality and low-cost healthcare services.

While Lean Six Sigma was built on Six Sigma’s original Define-Measure-Analyse-Improve-Control (DMAIC), and Define-Measure-Analyse-Design-Verify (DMADV) roadmaps, it is a data-driven, process-oriented continuous improvement approach that focuses on identifying and eliminating process defects, variation, and non-value-adding time to improve healthcare service efficiency and effectiveness.

Simultaneously, it helps improve process flow, utilization, flexibility, and service capability towards delivering greater value to patients and other healthcare beneficiaries.

There is an increasing interest in Lean Six Sigma by healthcare practitioners. While it offers both process and data lenses to examine problems towards a resolution roadmap, practitioners endorse it to be easy to learn and effective when applied.

We had opportunities to apply Lean Six Sigma in Indian hospitals. For example, a multi-specialty hospital in India that we deployed Lean Six Sigma suffered from a low patient satisfaction rate of about 78 per cent in the cardiology department.

The turnaround time (an average of 315 minutes, with a standard deviation of 24 minutes) was reported as a major contributor to patient dissatisfaction and identified as an opportunity for process improvement by the department’s management. Data analysis revealed a poor process capability to deliver services within the set objective of 210 minutes.

By applying the Lean Six Sigma toolkit, we were able to identify the root causes of the problem. Lack of scheduling, incomplete patient information, lack of test result alerts, lack of clarity in patients about the hospital layout, workstation downtime, delays from other appointments, and demand fluctuations were a few of the root causes.

Lean Six Sigma tools like Pareto analysis, Control charts, Value Stream Maps, and data analytics were used as part of the project.

The integrated mobile alert system, standardising the lab data reporting, revamping the scheduling system, eliminating non-value adding activities and process bottlenecks, staff training, etc., were a few improvements executed in the cardiology department.

Consequently, the turnaround time was reduced to 240 minutes, with a standard deviation of 9 minutes. The Lean Six Sigma project delivered an annual cost saving of about INR 3.4 million, increasing patient satisfaction to 91 per cent.

Further, it contributed to learning, excitement in the participating stakeholders towards a cultural change. Customer centricity, process orientation, data-driven decision making were a few learnings highlighted by the participants. 

In another Indian hospital, the accuracy of the Medical Records Department was improved from 89 per cent to 97 per cent using Lean Six Sigma. Another example was reducing the turnaround time in a mobile hospital that provides free medical services to ~3000 villages in the Indian state of Andhra Pradesh, using Lean Six Sigma’ss DMADV methodology.

In another assignment, we noted a significant reduction in medical insurance claims from 1.5 per cent to 0.8 per cent. Here, by improving the process sigma value from 3.66 to 4.52, the healthcare firm realised a cost avoidance benefit of about INR 38 million. 

An overview of research literature on Lean Six Sigma indicates that ~20 per cent of publications on Lean Six Sigma in services sectors are specific to healthcare. This shows an increasing interest in Lean Six Sigma by healthcare practitioners.

While it offers both process and data lenses to examine problems towards a resolution roadmap, practitioners endorse it to be easy to learn and effective when applied.

Thus, it will be a worthy future direction for healthcare professionals like doctors, administrators, lab personnel, and other clinical and non-clinical technicians to learn and apply Lean Six Sigma for continuous improvement. 

Alongside management learning, it sets an agenda for total personnel participation towards building a continuous improvement culture (beyond individual projects), a critical gap to bridge, and a worthy opportunity to pursue in the healthcare space.

With digital automation, robotics, and information and communication technologies being applied faster in healthcare institutions, it is important for them to embark on the Lean Six Sigma journeys. As a pre-requisite to technology deployment, Lean Six Sigma would help hospitals and other healthcare institutions streamline their processes and improve them as deserving candidates for digitisation.

The writer is an Assistant Professor of Practice at the Indian School of Business (ISB), Hyderabad, India. He is a Lean Facilitator and Six Sigma Master Black Belt practitioner, and an Affiliate Faculty with the Max Institute of Healthcare Management (MIHM) at ISB.

The Hard Work of Health Care Transformation

03/18/2020 3:36 pm

Richard M.J. Bohmer, M.B., Ch.B., M.P.H.

Governments and regulators influence the performance of health care organizations and practitioners primarily through positive and negative financial incentives, regulatory constraints on their licenses to practice, and support of performance-improvement activities through education, research, and measurement programs. The financial approaches aim to motivate change in the way organizations and practitioners configure their systems and deliver care, under the assumption that once they’re motivated to seek surplus or avoid sanction, they’ll be willing and able to make local operational changes to reduce cost and improve safety, patient experience, and outcomes. Unfortunately, experience shows that although a changed market may be a helpful precondition to local performance improvement, it hardly guarantees effective operational change.

Some organizations have successfully transformed themselves, however, substantially improving efficiency and quality. How have they done so? One popular approach is top-management–led structural and governance change — moving boxes on organizational charts of an individual entity or regional system. Services are merged or broken up, new roles defined, and new responsibilities assigned. This approach appeals to boards, CEOs, and consultants because big changes can be made rapidly. But such rearrangements may disappoint.1 Examination of organizations that have achieved and sustained substantial performance improvements reveals that lasting transformation requires the relentless hard work of local operational redesign.

Organizations’ delivery of care is ultimately governed by structures and processes at the ward, clinic, or practice level. These elements have usually accreted over time, often in response to regulations or technology and without subsequent performance review or deliberate updating. In contrast, successful “transformers,” from Seattle’s Virginia Mason Medical Center to the Salford Royal National Health Service Foundation Trust in England, constantly make small-scale changes to their structures and processes over long periods.2 Everything from communicating with patients to cleaning gastroscopes to ordering tests and choosing therapies has been subject to redesign. Major change emerges from aggregation of marginal gains.

These organizations’ experiences clarify that multidisciplinary teams must undertake this redesign work.3 The provision of modern health care integrates so many specialized skills — clinical and nonclinical — and patients routinely cross so many intra- and interorganizational boundaries that no single designer can create a highly functioning microsystem. Such teams often have diverse membership, including not only patients, referring doctors, corporate staff, and community service providers but also design engineers. When these teams redesign local structures and processes, they do more than write a “best practice protocol.” They also reconfigure the workflow, workforce, supporting technology, and even physical care delivery sites.

Other hard truths emerge from studying successful organizations. Teams often redesign local structures and processes despite the lack of senior support, adequate data, capital, or a reimbursement system that rewards their efforts. Although consultants routinely list support from senior leaders as a key prerequisite for change, initiation and early leadership of such teams often comes from the middle — committed clinicians and managers volunteering early mornings and late evenings to create better-functioning systems for their patients. Teams use whatever imperfect data are available, often collecting essential data by hand; they recognize that important organizational design decisions are often made with insufficient information. And few redesigns get it 100% right the first time. In practice, health care transformation is a long series of local experiments.

Transformation requires sustained change in individual behavior, team interactions, and operations design. Although consultants and information technology vendors can help, experience has shown that more than anything, change depends on internal redesign work.

If detailed, low-level, repetitive redesign of local operating systems one at a time is the reality of improving health care, how do successful transformers support their staff through that process? How do they change in a systematic way? And how can organizations seeking transformation make the process easier and faster than it was for the vanguard?

Examination of high-performing organizations suggests seven essential organizational elements that support orchestrated team-based redesign. First, these organizations deploy many redesign teams concurrently — some permanent, some temporary. Virginia Mason convenes small teams transiently to redesign key processes, whereas Intermountain Healthcare (Utah and Idaho) has a permanent team structure responsible for redesign and long-term oversight. Both organizations have developed expertise in managing multidisciplinary teams.

These redesign teams are typically led by clinicians, although managers are well represented. They aim to improve the quality and the efficiency of care simultaneously, and the organizations see no conflict between those goals. Because many clinicians don’t feel empowered or prepared to lead such efforts or feel comfortable with resource stewardship, transformers invest heavily in leadership development, usually creating their own leadership programs rather than outsourcing them, and they free leaders from some clinical duties to create sufficient time for this work.

Transforming organizations have a routinized process for change. The basis for their standardized approach to analysis, redesign, improvement, and management varies, but what’s most important is not which model — lean manufacturing, continuous improvement, six sigma — is chosen but that the process is internalized, repetitive, and consistent so that the same language is used throughout the organization and independent teams can undertake redesign autonomously.

In addition, these organizations have an internal support resource that includes skills in design, project management, data analysis, financial analysis, and organizational development. Organizations may be tempted to rely on management consultants for support, but the transformers have worked to develop these capabilities internally.

They also have well-developed measurement systems that include both a capability for developing or reviewing measures of clinical or financial performance and the capacity to collect, report, and act on internally generated data. Data are often an Achilles’ heel: few doctors believe they have adequate data for system redesign. Transformers, however, do the best they can with available information, recognizing that data will improve over time. They address clinicians’ need for evidence-based decision making by treating design change as a test of concept, rather than implementation of a known answer. Redesign becomes a process for testing new metrics and data sources, which can, over time, mitigate short-term data inadequacy.

Furthermore, a senior oversight group is responsible for establishing teams, setting their priorities, monitoring their progress, addressing institutional barriers to change, and integrating multiple teams’ work. This group ensures that teams remain focused on organizational priorities and have the necessary resources, and it resolves conflicts that arise when multiple groups make demands on shared resources. The teams thus become part of a broader structure for clinical governance and form the core of performance-management and improvement efforts. At Intermountain, the permanent teams both redesign and manage care systems.

Finally, because any model of team-based redesign devolves authority and accountability away from top executives, transformers have invested in creating a widely understood set of unifying values and norms. Whether expressed in value statements, compacts, or credos, these standards help align staff behavior both with the organization’s goals and among the professions working together to meet those goals, and they guide behavior when there’s no clear decision rule.

Many organizations find this approach challenging, and not only because it’s slow or requires investment. It also risks requiring job cuts, or at least job changes. Most challenging, however, is the fundamental change it represents in an enterprise’s governance. Clinician-led teams take control of patient-facing organizational subsystems and reform clinical protocols and operations, review performance data and make modifications, and may even have local financial control and responsibility. In effect, instead of taking their work context as a given, staff actively create the local system needed to provide the best possible care. This shift may be a bridge too far for some organizations, especially those facing reduced revenue or an urgent need for a turnaround.

Unfortunately, in the longer term, the prolonged hard work of repetitive, incremental, and often small-scale rebuilding of local operating systems probably cannot be avoided. Individual behavior change motivated by payment reform may be insufficient to generate the quality and efficiency gains needed in coming years. In their first year, the Pioneer Accountable Care Organizations have achieved only modest results.4 However, organizations seeking transformation can ease the process by building the support system described above. The short-term investments that are required can be surprisingly small, because most organizations already have many of the requisite human assets. The most substantial hurdle, it seems, is the change in mindset.

Making the Journey Toward Culture Change in Healthcare

03/09/2020 5:09 pm

By Anita M. Yelton

Recognition is growing among healthcare leaders of the need for a culture change within their organizations. Moving from recognition to reality, however, is more difficult. The problem lies in the perception – or misperception – of what a culture change actually entails.

Culture change is not a program with a completion date, nor is it a quick fix. It is an ongoing journey – a journey that requires leaders to understand the current state of the organization, establish a clear vision, align behaviors and instill accountability.

Vision Versus Cultural Reality

Facing the need for a culture change, large corporations, not-for-profit institutions and faith-based organizations all say the same thing: “We’re different, we’re unique.” But actually, they share many common challenges and objectives. They all hire people with goals and ambitions, and with expectations as to how they will be treated, accepted, rewarded and promoted.

All too often, however, employee expectations and those of the organization are not fully aligned. This may be despite what the organization professes as its objectives. For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.

Many senior executives are out of touch with the realities of their organization. Typically, leadership only discovers what is really going on when employee surveys come back with unexpected results. Such evidence dissolves complacency and compels action. In fact, this awareness is usually where the real journey toward culture change begins.

Achieving a culture change within an organization is an ongoing process involving deliberate, intentional steps that include:

  • Knowledge and Awareness
    • Honest assessment of the current culture
    • Development of baseline data
    • Vision of the desired state
  • Recognition and Reward
    • Demonstration of desired behaviors
    • Encouragement and reward for desired behaviors and outcomes
    • Determination of the decision-making process (who, what, when, how)
  • Communication
    • Development of an organizational communication strategy
    • Delivery of consistent messages throughout the organization
    • Frank discussion of tough issues that are frequently avoided
  • Systems, Structures and Linkage
    • Alignment of top leadership and performance management with the organization’s core values and issues
    • Determination of core competencies to support the desired culture
    • Delineation of goals – including “stretch” goals – for leadership
    • Linkage of behaviors, goals and achievements to compensation

Building a Framework for Change

Much can be learned from the successes and failures of organizations attempting to implement large-scale change initiatives. Such an examination reveals the value of using proven tools and techniques such as change acceleration process (for rapid decision-making), Work-Out (when the problem is known but the solution is not) and Lean Six Sigma (to streamline processes and reduce variation). These techniques can give employees a solid framework for addressing the issues they confront on a daily basis.

A simple equation to communicate this framework for sustainable change is Q x A = E, or the quality of the solution times the acceptance of that solution will equal the overall effectiveness. The individual components may be considered common sense, but they are not necessarily common practice.

In addition, it is important that this framework also include:

  • Clear management and leadership systems with 360-degree feedback
  • Skip-level meetings (meetings where leaders bypass their direct reports and speak to the next level of the organization)
  • A consistent operating calendar
  • A linkage between people, strategy and results.

The mere existence of an internal quality program cannot bring about a culture change. Leaders must focus on and balance all elements of the equation to begin the journey toward change and achieve sustainable results.

10 lessons‘A’ Side of Equation Is Essential

Employee acceptance is essential. Many organizations have declared their mission, written goals, produced vision statements and embraced a philosophy or set of values that fits their organization. These affirmations often include such lofty themes as empowerment, boundarylessness, customer focus, passion for excellence, accountability, quality mindset, employees as partners and so on. They are conveyed to all employees, reinforced in communication and are used to measure performance.

However, often there is no structure to support the realization of these organizational objectives. The employees frequently lack a genuine commitment to their company’s stated goals, mission, value statements and general philosophies because:

  1. They feel they have no input into the process.
  2. The statements are long, vague and do not relate directly to employees’ work.
  3. Goals and values are only communicated once a year and then not mentioned again.
  4. The statements are constantly being changed or revised.
  5. The leadership team is inconsistent in its actions and behaviors in support of the goals and values.

The failure to support goals and values could stem from such management practices as giving individual rewards and recognition versus team projects and rewards; identifying and grooming individuals with high potential for selected management positions while ignoring others who contribute to the team’s success; relying on employee comparisons and rankings that may be subjective instead of objective; discriminating within training, development, salary and promotions; and talking to instead of with employees. Other problems could include leadership actions that fail to “walk the talk,” an unwillingness on the part of management to accept feedback, a lack of upper management diversity and high turnover.

Such organizational shortcomings are often a matter of focus. In an effort to reduce cost, raise quality, boost productivity and surpass the competition in the marketplace, management may neglect such issues without realizing the impact it can have on employees, and thus the entire organization. Further, when confronted with the problems of stressed, overworked and burned-out employees, management often dismisses the complaints as trivial. The employees are sometimes labeled as “not being team players” or “not the stuff leaders are made of.”

The general feeling is that “healthcare is a caring profession” – an environment in which it is difficult to discuss performance issues. Tough conversations about people and performance often do not take place in order to avoid difficult or confrontational situations. Action items, decisions and accountability may never be discussed in meetings, where behavior is polite and politically correct. In fact, some of the most important conversations and decisions take place in the hallways after meetings. The fact to remember is that, wherever they take place, face-to-face communication is critical to establishing an honest, open dialogue across the organization.

Conclusion: A Path Toward Culture Change

Healthcare faces many challenges today in the quest to deliver the best and most cost-effective services for patients. One important challenge is to institute a culture change that enables staff, clinicians and managers to feel empowered and adequately equipped to address the problems which can be resolved only by altering their work environment. They need to know they can propose and implement viable solutions to real problems. Visionary healthcare organizations that are seeking to transform the way they deliver care must begin by finding a path toward a culture change.

Fewer X-Ray Errors Reduce Cancer Risk, Wait Time and Costs Evan McLaughlin 27

02/28/2020 5:49 pm

Evan McLaughlin 27 November, 2019

Clinicians examining a radiograph

In hospital and clinic settings, making the right decisions doesn’t just reduce costs from duplicative work and process inefficiencies — it results in better outcomes for patients. Think about needing to take an extra X-ray because the first captured the wrong foot. Even if it’s the right limb, what if they captured it from the wrong angle?

Over the 14 years he worked in healthcare quality improvement, Art Wheeler saw this and many other process improvement scenarios. Most recently, as decision support manager for quality improvement services at one of the country’s largest not-for-profit freestanding pediatric healthcare networks, he was the primary statistician, as well as a mentor and coach for Six Sigma Black Belts and Green Belts, program managers and project leaders for 8 1/2 years.

An expert in statistical quality control, one of his key responsibilities was ensuring data was collected in a way that was sound and ensured the best chances for detecting statistical significance of any reported improvements. He also developed the charts and writeups for the analysis sections of corresponding published articles and responded to reviewer questions or comments to help ensure acceptance.

Remember that extra X-ray scenario we mentioned earlier? Art served as a consultant on a duplicate X-ray study, which found each unnecessary scan cost facilities an extra $150 to $300 and overall patients were waiting longer. One study of 18 US pediatric emergency departments showed radiology errors are the third most common event in pediatric emergency research networks and human errors rather than equipment issues caused 87% of them.

Besides reducing errors, the team were also motivated to achieve their goal of zero errors at two clinics so they could also reduce lifetime radiation exposure for individuals, which in turn diminishes their risk of developing cancer. Efforts like this were part of the hospital’s “Zero Hero” program – they would measure the time period and the number of cases involved, aim to reduce incidents to zero and record how long they maintained zero incidents.

It wasn’t all black and white though. They needed to understand the context behind the duplicate X-rays to truly make improvements. With a retrospective review of a 14-month period at two facilities, they knew there were good and bad reasons behind the 170+ duplicate X-rays that were recorded, for a duplicate radiograph. Each duplicate radiograph was classified as …

  1. No error, where they intentionally studied from multiple views;
  2. Incorrect location, when the patient’s initial complaint did not match the initial radiograph (e.g. the aforementioned wrong foot);
  3. Incorrect laterality, when it’s the wrong side; or
  4. Unnecessary radiograph, a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment.

The Pareto chart below shows the most common error during the 14-month period was incorrect location.

pareto-chart-radiograph-error-classification-resize

The quality improvement team took steps to meet their zero percent goal in both clinics, which included issuing surveys to patients and families during registration to help document where they needed to be X-rayed and if they had been X-rayed in the past.

The unnecessary radiograph was also a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment. An intervention was made to fix this, making physicians responsible for putting their own radiograph orders in the Electronic Medical Record.

Overall these steps improved communication between physicians, clinical athletic trainers, radiology technologists, patients and families, and greatly contributed to better outcomes for everyone involved.

Lean Healthcare Project Teams

The Performance Management Group (TPMG) announces its 3rd Quarter Lean Six Sigma Excellence in Healthcare Delivery Certification Graduates.

08/30/2018 7:16 pm

8/30/2018 – Phoenix, Arizona  USA

The Performance Management Group (TPMG) announces its 3rd Quarter Lean Six Sigma Excellence in Healthcare Delivery Certification Graduates.

TPMG Education Services would like to congratulate its 3rd Quarter 2018 Lean Six Sigma Certification Graduates.

This accomplishment acknowledges they have fulfilled the requirements for the program of study and, from this day forward, they are certified as Lean Six Sigma Green Belts and Black Belts.  This designation is conferred upon them as of Friday August 24, 2018.  They are now authorized to place their respective “LSSBB” or “LSSGB” designation, which acknowledges this credential, following their name.

Congratulations Lean Six Sigma Black Belt Certification Graduates:

  1. Joyce Taylor, Director – Telligen
  2. Janice L. Stanton ,  Manager of Pre-Design Services – Gresham, Smith and Partners
  3. Ann Hastings, Business Intelligence Data Analyst – St. Luke’s Health System
  4. Ismael Groves – Director of Program Operations, Consumerism – Banner Healthcare

Congratulations Lean Six Sigma Green Belt Certification Graduates:

  1. Landin Shan, Project Manager of Shanghai Market – Shanghai United Healthcare
  2. Solomon Fatima, A/R Management Supervisor – Shanghai United Healthcare
  3. May XU, Outpatient Cashier Supervisor – Shanghai United Healthcare
  4. Clement Qi, IT Manager of Shanghai Market – Shanghai United Healthcare
  5. Susan Fang, Clinical Manager – Shanghai United Healthcare
  6. Sabeen Irfan, Clinical Operations Manager – Shanghai United Healthcare
  7. Zhang Ying, Lab Associate Manager – Shanghai United Healthcare
  8. XiaoMeng Sun, Medical Staff Office Supervisor – Shanghai United Healthcare

For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to http://www.helpingmakeithappen.com.

How Hospitals Can Raise Patient Satisfaction, CAHPS Scores

08/01/2018 4:25 pm / Leave a comment

Sara Heath

Editor
sheath@xtelligentmedia.com

Improving patient satisfaction scores, such as CAHPS, is key for driving practice reputation and reimbursements.

Healthcare organizations with high patient satisfaction and CAHPS scores see a multitude of benefits. High patient satisfaction scores usually result in higher reimbursement payments from CMS, better patient retention rates, and the assurance for hospital staff that they fostered a positive experience for patients.

A May 2016 report from Vocera showed that patient satisfaction is the top-ranked priority at healthcare organizations. Due to the importance of ensuring favorable feedback from patients, the demand for patient experience officers and patient advocate executives is increasing, with these professionals pulling equal rank with other C-suite executives, the report said.

The primary measure for patient satisfaction is the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The CAHPS survey is developed and funded by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS, and forms a component of some value-based reimbursement programs.

CMS also uses CAHPS scores to inform its star ratings, which are publicly available ratings about the quality of healthcare facilities.

Several types of CAHPS surveys are utilized throughout the care continuum, ranging from hospitals to nursing homes to health plans. However, the Hospital CAHPS (HCAHPS) and Clinician and Group CAHPS (CGCAHPS) are the most prominent and commonly used surveys.

Both surveys measure many of the same factors, including nurse care, doctor care, and facility environment.

The HCAHPS survey also includes questions about experiences within the hospital, including pain management, and continuity of care experiences.

CGCAHPS surveys target their questions to the general practitioner, asking questions about ease of healthcare access and how often the patient has been visiting the office.

Because HCAHPS and CGCAHPS are used for both reimbursement and patient rating purposes, it is important for healthcare organizations to improve their scores. Healthcare organizations can improve their CAHPS scores by understanding what is important to patients, what the surveys measure, and how to meet patient needs.

Improving Patient-Provider Communication

Provider Picture

The first two sets of HCAHPS questions pertain to nurse and physician communications with patients. These questions ask whether nurses and physicians communicated clearly with patients, and whether patients understood their diagnoses, prognoses, and treatment options.

Clear communication about healthcare information is integral to a positive healthcare experience, experts say. Hospitalization is often a stressful and worrying time for patients, and made even worse when clinicians do not adequately communicate what is going on and how they will treat a patient’s ailments.

In addition to allaying patient worry, providing meaningful explanations of conditions and treatments will help the patient taken ownership of her own health.

“Patients have a need for information,” explained Deirdre Mylod, PhD, Executive Director of the Institute for Innovation and Senior Vice President of Research and Analytics at Press Ganey.

“It’s not just making consumers happy to meet that need, but it’s also providing the right care. When you give people the right information, they can engage in care, they can be active participants, they’re better prepared to care for themselves at home, they’re less likely to be readmitted.”

Clear communication will require collaboration between the different members of the care team, added Mylod.

“As a patient, when one team member tells me one thing and somebody else tells me another, now I’m afraid and I’m thinking you’re not working together. Now I’m more scared than I need to be in a hospital,” she pointed out.

HCAHPS also asks patients whether nurses and physicians treated them with respect and empathy. Clinicians must tap into their interpersonal skills to provide compassionate care to their patients, while being mindful of cultural norms and barriers.

The healthcare industry might be falling short in this respect. A January 2017 survey conducted by Oliver Wyman and the Altarum Institute found that 40 percent of low-income patients have walked away from appointments feeling disrespected.

The survey, funded by the Robert Wood Johnson Foundation, showed that in addition to reducing patient satisfaction, lacking compassion also lowered quality of care. Patients who felt disrespected were three times less likely to trust their clinicians, and two times less likely to adhere to treatments.

Healthcare organizations should support their clinicians in pursuit of being more empathic. Organizations can host cultural sensitivity seminars, work with patients to continue to develop their interpersonal skills, and educate clinicians on evidence-based best practices for enhancing patient-provider communication.

Improving the Physical Hospital Environment

Hospital Setting

Two HCAHPS questions pertain to the hospital environment: hospital cleanliness and hospital noise levels.

In order to maintain an appropriately clean and sanitary facility, organizations must support their custodial staff and reinforce the importance of a healthcare facility being clean.

The American Hospital Association has long advocated for improving the hospital setting for patient satisfaction. In a 2016 guide, AHA listed the ways in which organizations can create environments more suitable for patient rest and recovery.

To create a quiet and peaceful environment, AHA says hospitals should implement and enforce rules about quiet hours and lights-out times.

“It makes sense that patients rate hospitals poorly when they cannot get good sleep or rest and have the additional stress of noise added to the already stressful situation of being unwell,” AHA wrote. “Data shows that noise in hospitals is the factor that scores lowest on HCAHPS scores nationwide.”

Healthcare organizations can take it a step further than HCAHPS mandates. Many hospitals are turning to their patients to inform room design that will facilitate a more comfortable experience.

When designing its new facilities in Delaware and Orlando, leaders at Nemours Children’s Health consulted with its patient and family advisory board to decide which features would best suit pediatric patient rooms.

“The parents came in and tested all of the furniture that they might be sleeping on in the rooms. They provided input into what we actually purchased,” recalled Nemours Chief Information Officer Bernie Rice.

“The children came in as well and helped pick colors and room layouts as far as if the counter was too high,” he continued. “They were very valuable and heavily influenced our construction and design to make sure it was a very family- and patient-friendly environment.”

Being Attentive and Reducing Unnecessary Discomfort

Improving Patient Discomfort

One highly-debated part of patient experience surveys is pain management. Amidst a raging opioid abuse epidemic, many experts question whether pain management should be a part of patient satisfaction scores that result in provider reimbursements. By tying payments to pain management, some clinicians may feel compelled to prescribe opioids when there could be other potentially less-risky forms of pain management.

In November 2016, CMS removed the pain management questions from the HCAHPS survey. However, the agency maintained that pain management is an important part of patient care and experience.

“CMS continues to believe that pain control is an appropriate part of routine patient care that hospitals should manage, and is an important concern for patients, their families, and their caregivers,” CMS said in a public statement. “CMS is continuing the development and field testing of alternative questions related to provider communications and pain, and will solicit comment on these alternatives in future rulemaking.”

While the pain management portions of the HCAHPS survey are currently under construction, clinicians should still work to reduce unnecessary patient discomfort.

Press Ganey is adopting this approach when consulting on patient experience, Mylod said.

“The way that we approach improvement for patient experience measures is to reframe it,” she explained. “The exercise is not to make consumers happy. The exercise is to reduce patient suffering.”

To boost scores in this realm, Mylod suggests clinicians – especially nurses – become even more attentive. This means not only answering call buttons, but also making regular rounds to hospital beds to ensure they meet all patient needs.

During these rounds, nurses can ask if the patient needs assistance using the restroom or if they need an object, such as a television remote, handed to them. Paying attention to these seemingly inconsequential needs could reduce adverse safety events, Mylod explained. If a patient gets up to retrieve a book, for example, he could fall and hurt himself, affecting the patient experience, increasing length of stay, or requiring additional expenses related to an injury.

Streamlining discharge processStreamlining the Discharge and Follow-up Process

HCAHPS asks patients about how doctors and nurses managed continuous care and the discharge process. The survey asks whether clinicians checked in on post-discharge care plans, made it clear which provider will follow-up with ongoing needs, and whether that care will be adequate for the patient’s condition.

At patient advocacy group Planetree, leaders have developed a hospital discharge plan to ensure clinicians meet patient needs.

The plan includes identifying a family care partner that will help take care of the patient following hospital discharge, said Planetree’s Director of Research Jill Harrison, PhD.

From there, clinicians check in with the patient and appointed caregiver to determine which functions they will need to learn for optimal at-home care.

“Planetree has a program that allows people to say that they want help with wound changes, or help ambulate their loved one, or help check a tracheotomy if the patient has one,” Harrison said. “Caregivers go through a training program with the nursing staff and learn how to provide that care so that when patients get out of the hospital setting their family members are ready to take that all on.”

Other key healthcare players are advocating for a similar strategy. AARP has been sponsoring a law in state legislatures across the country to support family caregiver engagement. The organization says caregiver engagement will help support continuity of care.

Research confirms that family caregiver engagement can reduce hospital readmissions by up to 25 percent.

Hospitals that implement family caregiver engagement and discharge plans may see not only increases in HCAHPS scores, but in quality of healthcare, as well.

The importance of improving patient satisfaction and CAHPS scores is well-founded. These scores help inform CMS value-based reimbursements and hospital ratings published on the CMS website. Many healthcare organizations also use these scores to inform their own internal practice improvement processes.

However, when it comes to improving patient satisfaction, it is also important for practice leaders to look beyond the survey. Improving patient satisfaction means understanding the facility’s unique patient population and its needs. What will please one group of patients may not satisfy another, and hospital leaders must bear that in mind.

While supporting initiatives specifically geared toward improving CAHPS scores, healthcare organizations should also consider projects that will serve their unique population.

Issuing practice-specific patient input surveys or consulting with a patient advisory council will help healthcare organizations move beyond surface-level satisfaction and find solutions that will be truly meaningful for patients.

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

The Heart of the Matter: Hospital’s Improved Diagnostic Process Saves Lives and Money

01/15/2018 1:30 am

You expect to find many lifesaving techniques in hospitals—expensive medical research, groundbreaking procedures—but when it comes to treating patients with cardiovascular disease, the approach one Taiwanese hospital used might surprise you: data analysis.

Heart disease is one of the leading causes of death in Taiwan, so it’s no wonder the country’s healthcare professionals are looking for ways to improve treatment options.

That’s why a Lean Six Sigma project team at Cathay General Hospital in the city of Taipei examined the emergent angioplasty process for treating patients suffering from acute ST-elevation myocardial infarction (STEMI), a heart attack caused by coronary heart disease. Improving aspects such as the wait time between diagnosis and treatment could help to save many lives.

Doctors and quality managers from the hospital’s Quality Management Center used Minitab Statistical Software to assess the hospital’s process and confidently re-engineer both the diagnosis and treatment processes while increasing savings in medical resources.

The Challenge

A project team at Cathay General Hospital used Minitab Statistical Software to analyze data that would improve treatment for patients suffering from heart attacks. Above, the hospital is shown in its Taipei City, Taiwan, location.

Patients with STEMI are diagnosed through electrocardiogram findings and cardiac markers, and the recommended course of treatment for these patients is angioplasty completed within 90 minutes of arrival.

Medical professionals refer to this period as the door-to-balloon (D2B) time, because angioplasty involves inserting a small balloon inside the blocked blood vessel with a catheter. When inflated at the site of the blockage, the balloon enables blood flow to resume.

To maximize the patients’ chances for survival, the team needed to evaluate each step of the process. They needed to identify which variables were responsible for a D2B time that exceeded the recommended treatment time, and, more importantly, what adjustments could be made to minimize it.

How Minitab Helped

The team analyzed D2B time—which includes an electrocardiogram, the wait time before the operation, and the time for balloon inflation—using Minitab Statistical Software.

However, you can only trust the results of an analysis if you trust the data you’re analyzing. To ensure the data were trustworthy, the project team used Minitab to conduct a Gage R&R Study of their measurement system. This method evaluates a system’s precision, including its repeatability and reproducibility to ensure that measurements are consistent and reliable.

Minitab’s Assistant menu makes it easy to choose and use the right tool, even if you’re not a statistician. The dialog box above helps users create a data collection worksheet for a Gage R&R study.

Once they verified the precision of their measurements, the team analyzed D2B data from 40 STEMI cases that occurred over a nine-month period.

First, they tested the data to see if it followed a normal distribution, which is a key assumption in many types of analysis. The data were not normally distributed, but using Minitab the team easily applied a Box-Cox transformation to normalize it. The team then used the transformed data to create an I-MR control chart to evaluate if their process was stable over time. This type of control chart plots both individual observations (I) and the moving ranges (MR) to show how the mean and variation in the observations change over time.

The I-MR control chart above displays the normalized data from the Box-Cox transformation and identifies unusual sources of variation in the data.

The project team also used Minitab to conduct a process capability analysis to determine whether their process met performance specifications and provide insight into how they might improve their process. In this case, the upper specification limit for D2B time was 90 minutes. The results of the capability analysis confirmed that the hospital’s handling of STEMI cases had significant room for process improvement.

The team examined each step in handling a STEMI patient and identified several areas in which efficiency could be significantly enhanced, including confirming the diagnosis, medicating the patient, preparing for the operation, transferring the patient to the catheterization laboratory, and inflating the balloon.

Results

After assessing the STEMI process, the team implemented improvements such as sending patients who arrive with chest pain directly to an electrocardiogram test, printing treatment sheets automatically as opposed to writing them by hand, making a STEMI medication pack available in the emergency department, contacting the catheterization staff upon diagnosis confirmation, prepackaging all STEMI operation equipment in one box, and discontinuing the use of operation time as a forum to teach staff members who are not familiar with the procedure.

The team then collected additional data and reevaluated the process. Using Minitab to analyze the new data, the team demonstrated that the average D2B time dropped from 139.2 to 57.9 minutes—a 58.4% improvement. Furthermore, capability analysis showed that this new process could meet specifications.

A more efficient process means patients receive angioplasty more quickly, which saves lives. Moreover, the average hospital stay for STEMI patients has decreased by three days since the new process was implemented, and the hospital has saved $4.4 million in medical resources. The project was recognized by the Taiwan Joint Commission of Hospital Accreditation, and was awarded the Symbol of National Quality by the Institute for Biotechnology and Medicine Industry.

Applying data analysis and Lean Six Sigma methods to the health care system doesn’t grab headlines like an experimental surgery might. But as more hospitals use data analysis to make procedures better, faster, and safer, its benefits will be seen every day in the faces of patients whose lives are saved.

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

01/10/2018 7:56 pm

Serious about Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

 Akron Children’s Hospital is serious about enhancing the patient experience, along with delivering quality healthcare in a timely, efficient manner. While the hospital formally established the Mark A. Watson Center for Operations Excellence in 2008, it has been performing quality improvement since its early beginnings 125 years ago. It’s no wonder the healthcare provider has consistently earned Best Children’s Hospitals rankings in 7 of the 10 specialties evaluated annually by U.S. News & World Report—including cancer, diabetes and endocrinology, pulmonology, neonatology, neurology and neurosurgery, and orthopedics.

The hospital encourages employees across all skill levels and departments to become involved in quality improvement, offering several levels of Lean Six Sigma training. As part of its green belt training and certification, employees learn to use Lean Six Sigma by leading and completing long-term projects with the guidance of experienced black belts.

One such green belt project, which began at the hospital’s Mahoning Valley, Ohio campus, had a goal to decrease one particular safety event—unplanned extubations in the hospital’s neonatal intensive care unit (NICU). To complete this project, the hospital improvement team relied on Lean Six Sigma tactics and the data analysis tools in Minitab Statistical Software.

The Challenge

Akron Children’s Hospital relies on Minitab Statistical Software to analyze their Lean Six Sigma project data. The hospital used Minitab to verify improvements made to the intubation process in the NICU.

An intubation is a medical procedure in which a breathing tube is placed into a patient’s trachea. This tube connects the patient to a machine called a ventilator, which helps the patient breathe. The procedure is common for both pediatric patients and adults in intensive care, but is most common for premature newborn babies residing in a hospital’s NICU. Babies born prematurely often have undeveloped lungs, which cause breathing problems and the need for the assistance of a ventilator.

Although this medical procedure is commonly performed, it is not without risk, and can cause trauma to or introduce an infection into the patient’s airway. Unplanned removal of the breathing tube, which is also known as an unplanned extubation, is a likely occurrence that can cause harm. Unplanned extubations are the fourth most common adverse event in NICUs across the U.S.

Akron Children’s Hospital’s Department of Respiratory Care had been collecting data on the rate of unplanned extubations in the Mahoning Valley NICU for well over a year, but had not had the capacity to investigate the occurrences further. Bonnie Powell, a Registered Respiratory Therapist and manager of respiratory services at Akron Children’s Hospital, was a green belt candidate during the time unplanned extubation data were collected. As part of her Lean Six Sigma training and certification, she set out to lead a project that would decrease the rate of unplanned extubations in the Mahoning Valley NICU.

“I knew this project was the perfect fit for me because as a respiratory therapist, I’ve been part of the frontline staff primarily responsible for intubating,” Powell says. “When you’re the one actually putting the tube into the patient, it just affects you more because you know the trauma that you could be causing to them.”

How Minitab Helped

While there’s not a true benchmark rate that NICUs should strive to stay below regarding unplanned extubations, the Vermont Oxford Network—a research collaboration of nearly 1,000 global NICUs including Akron Children’s—considers 2 in 100 intubated patient days to be the upper limit of acceptable. Previous data collected on the rate of unplanned extubations at the Mahoning Valley NICU revealed a rate of 3 in 100 intubated days.

“Any unplanned extubation has the potential to cause harm to the patient and negatively impact overall patient satisfaction,” says Powell. “We wanted to improve our performance on this metric.”

Powell’s Lean Six Sigma project team included a multidisciplinary group of nurses, respiratory therapists, a neonatal nurse practitioner, and a neonatologist.

The team began by using Lean Six Sigma tools to brainstorm reasons why unplanned extubations were occurring, as well as solutions for stopping them. “The fishbone diagram and cause maps were among the most helpful tools we used,” Powell says. “We looked at the highest impact solutions, as well as how easy they would be to implement, and prioritized solutions from there.

“This step helped us to organize and roll out our seven improvements into two phases,” she says.

Along with more frequent communication between nurses and respiratory therapists before, during, and after an intubation, as well as educational information distributed in meetings and via email, one improvement implemented was the “two to turn” rule. “Anytime an intubated patient is repositioned, one caregiver is turning the patient and another is holding the tube at the patient’s mouth,” Powell explains.

The team applied the improvements for several months, as collecting enough data to meet the required 100 intubated days for pre- and post-improvement comparison proved difficult for many reasons.

“There is a continuing trend in neonatal care to use devices such as masks and nasal prongs to connect the patient to the ventilator to help with breathing. When these devices are used, there is no need for a breathing tube, which reduces the number of intubated days and lengthened our post-improvement data collection period,” Powell says. “That, coupled with greater attention to our weaning protocol, which focused on shortening the time babies need ventilator support of their breathing, contributed to why we saw a reduced amount of intubated days.

“Of course, fewer intubated days was a good thing in this case, and supported the idea that our improvements were working,” adds Powell.

To compare unplanned extubations, pre- and post-improvement, the team visualized their data using control charts in Minitab Statistical Software.

Minitab graphs clearly reveal the impact of improvement efforts. This control chart displays the reduction in unplanned extubations after Lean Six Sigma improvements were implemented.

To verify their results statistically, the team ran a 2 proportions test in Minitab to see if their unplanned extubation rates decreased after improvements were put into place.

Hypothesis testing in Minitab makes it easy to determine if there is enough evidence in a sample of data to infer that a certain condition is true for an entire population.

The analysis showed the team that after improvements were implemented, the unplanned extubation rate had indeed decreased.

The team also used Minitab to perform process capability analysis both pre- and post-improvement. This tool provided another before-and-after comparison of unplanned extubation rates, and aided the project team in assessing whether the new process was capable and in statistical control.

“I have never taken a statistics course and have no background in this type of work,” Powell notes, “but Minitab, coupled with the instruction I received from the Center for Operations Excellence, made it easy for me to analyze and understand my data.”

Trauda Gilbert, deployment leader for the Center for Operations Excellence at Akron Children’s, echoes Powell. “To be able to use Minitab to visually demonstrate the before and after effect with a control chart, which you can then share with your team and champion is really valuable. Minitab also makes it easy for front-line staff to document that they have made a statistically significant difference. To be able to do that without having to interact with a biostatistician or one of the other very rarely found statistical resources in our organization, is very beneficial,” she notes.

“Healthcare quality is a little different than manufacturing because we can’t just run a DOE and tweak a process line,” says Gilbert. “Even though we’re different, Minitab still helps us out.”

Results

The data revealed a dramatic reduction in intubated days after the improvements were made, as well as a considerable reduction in the rate of unplanned extubations at the Mahoning Valley campus. The reductions brought their rates in line with the Vermont Oxford Network’s suggestion of 2 unplanned extubations in 100 intubated patient days.

“This project showed us that simple improvements can create real change,” says Powell. “The cultural change this project instilled in our team was exciting—the recognition that even they could make a difference is huge.”

Cost savings resulting from the reduction in supplies and staff time needed to care for unplanned extubations can be calculated, but the overall financial impacts are hard to quantify. “The larger costs of unplanned extubations—such as a longer NICU length of stay, ventilator-associated pneumonia, and other setbacks that the patient can experience from the event—can be difficult to tease out,” Powell says.

“Neonatal patients are some of our key customers here,” she continues. “Due to the fact that they were born early, they come back to our institution for care frequently, especially initially. Making sure they have a safe experience early is critical, because the results of good care at this stage can have exponential benefits for patients in the future.”

In addition to improving the patient experience, the project helped Powell obtain her Lean Six Sigma belt certification. “I did get my green belt as a result, and we’ve also rolled out selected improvements to the NICU at our Akron campus,” she says. “We’re in the process of collecting data there as well, so this project didn’t just stop in Mahoning Valley.”

Powell’s project is just one example of an estimated 300 documented projects that have been completed throughout the Akron Children’s organization. The total financial savings of the hospital’s operations excellence program is estimated to be more than $25 million since its official beginnings in 2008.

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

Mapping the Healthcare Value Stream

11/15/2017 2:45 am

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