The Six Sigma Programme for The Healthcare

The use of Six Sigma is to improve business processes by eliminating the causes for errors that result in the shortcoming in products or services, essentially allowing an organisation to achieve the goal of streamlining their business processes so that they can provide the best products and services with a minimal amount of defects (3.4 defects per million opportunities). At this point, the organization is at a point where results are constant, stable and predictable. This is accomplished by implementing a management system that identifies errors systematically, followed by providing a range of methods to remove them. The methodology provided by Six Sigma is the DMAIC (Define, Measure, Analyse, Improve, Control) approach, which is used primarily for improving existing processes in a business. Six Sigma can benefit a hospital by cutting down on wasted time, whether it be the flow of communication of results from the lab to the patient, or the procedure of scheduling. By minimizing waiting time in both scenarios, a hospital will not only be able to provide better customer service, it can also have a major impact on its financial performance.

The ability to solve issues regarding variation in services allows for better resource utilization, meaning that more resources can be invested into other aspects of the hospital to improve customer experience and boost the odds of a customer returning in the future. The tools of Six Sigma used in the book “Lean Six Sigma Case Studies in the Healthcare Enterprise” (Sandra L.Furterer, 2014) within the DMAIC cycle are initial VOC, detailed VOC, Root Cause Analysis, Value Stream Map, PDCA, respectively. Whilst the tools mentioned can be effective, there are several tools that are more applicable to the healthcare industry. First of all, the use of Voice of Customer (VOC) is a tool suggested by the literature for defining and measuring the project goals, problems, improvement activities and customer requirements. This tool is a method of fact-finding from the customers to the management of the organization, which may include interviews, focus groups, complaints, and surveys. This provides information regarding customer expectations with respect to the service provided by the organization. Although the use of VOC is useful for an organization to understand customer expectations in many industries, it is a tool that can potentially be ineffective in Healthcare services.

The fact that customers (patients) at hospitals are normally under stress due to the nature of this service industry itself, it can be seen as inconsiderate and intruding to trouble them for feedback. This can either result in a lack of care in filling in a survey by a customer, which can lead to inaccurate information regarding their services. Furthermore, the process of VOC can be financially expensive. When taking into consideration the cost of implementing VOC along with the potential inaccuracy of information, this method does not prove to be ideal for a hospital to implement. When improving customer satisfaction in Hospitals, it is essential to identify service features that meet the Critical to the Quality tool. The book “Solutions to the Healthcare Quality Crisis: Cases and Examples of Lean Six Sigma in Healthcare” (Søren Bisgaard, 2009) states that “customer expectations are brainstormed and weighted”. This is in theory, ideal, owing to the fact that the research is based on brainstorming which does not involve a distressed patient’s input. Furthermore, it provides an accurate judgment, if executed correctly, regarding the factors that matter most in improving customer satisfaction. This brings in Kano’s model of prioritizing customer’s needs, which, when used in tandem with brainstorming, allows for a very effective methodology. Regarding the measurement phase, the book “Six Sigma for organizational excellence: a statistical approach”, (K. Muralidharan, 2015) recommends using the Data Collection Plan such as Checksheets. This method of data collection is simple and focuses on collecting data in real time.

The ability to classify issues into categories, whilst using a simple tally to record the number of issues give workers a visual overview of problem areas that need to be improved. This is an effective tool for hospitals to measure the number of errors in real time, which can help reveal areas that tend to cause most variance. The literature (Sandra L.Furterer, 2014) recommends the tool of Root Cause for the analysis of the processes to determine root causes of variation or chances of defects. This tool focuses on the identification of the potential impact of the event. Furthermore, this tool reveals the causes of errors after a problem occurs, making this tool an efficient one to implement, allowing the prevention of similar future events. The tool should ideally be applied as soon as the human error is detected. However, due to the fact that the Kano model will be used in the define phase, the Pareto chart method is the obvious tool to use as they compliment each other extremely well. Using Pareto charts will help the hospitals concentrate on elements that provide the most significant impact on the service of healthcare. Regarding the improving the process performance by addressing and eliminating the root causes identified in the Analyse phase, the literature (Sandra L.Furterer, 2014) recommends using the Value Stream Mapping technique of Lean Six Sigma.

The efficient flow of information and customers are crucial to not only the function of a hospital but also contributes hugely to customer satisfaction. This method can be seen to be ideal for improving services within the healthcare industry. Finally, the control phase of the Six Sigma DMAIC process involves executing a control plan to maintain and monitor progression after the improvement phase. This is to ensure that the expected improvement of a project has occurred. The literature (Sandra L.Furterer, 2014) recommends PDCA (Plan-Do-Check-Act), whilst the literature by (Søren Bisgaard, 2009) suggests using Statistical Process Control Charts as a mode of maintaining progression within the hospital. A flaw that makes the PDCA methodology not ideal for implementing on hospitals is that ignorance of the “people” element. Because of the constant change required for PDCA to work, workers have to constantly adjust, which can lead to workers in a hospital to be confused about relatively simple procedures. The SPC method, however, has the potential to incur a substantial cost upon an organization because of the need for professionals to ensure that the tool is used correctly. That said, a continuous review of improvements is vital for hospitals, and the fact that the SPC includes activities such as frequency of review and verification of system capability makes it one of the best tools for the control phase. The intellectual quality of analysis.

Although hospital staffs are not normally seen to be customer service providers, in reality, they are very similar to traditional customer agents in the way that customers view them. Customers at a hospital may judge the “quality’ of services based on factors such as the customer support, care provided, treatment with minimum delay and quick responses and communication attitude. In addition to the services provided by the hospital staff, hospitals must provide customer service in a range of the context such as the delivery of lab results and providing updates from patients in a timely and considerate manner, which can also influence a patient’s satisfaction with a hospital. Due to the fact that most hospitals that exist currently provide identical products and services, emphasis on customer satisfaction is important for a hospital to differentiate itself from the rest. Continuing with the aforementioned, customer satisfaction in hospitals relate to whether a customer feels that the Value Added services provided outweighs the Non-Value Added procedures, such as long waiting time prior to treatment, the acceptability of the hospital atmosphere, transportation convenience and even the ease of finding parking spaces. At the forefront of improving a hospital’s financial performance is cost reduction.

Optimising financial performance is key to hospitals due to reasons such as the continued weak economy and massive budget deficits. That said, the demand for hospital facilities remains high because of the on-going technological advancements, of which hospitals are required to procure. The most obvious ways to improve a hospital’s financial performance is by reducing the error rate of treatments and to efficiently allocate resources within it. To do this, the method of Six Sigma can help the hospital identify and solve issues in the delivery of healthcare. Kano Model Analysis is a tool that can be applied to the hospital to improve the general quality, as it helps in identifying opportunities for health service differentiation. Kano analysis involves classifying customer preferences into three main categories: Basic attributes, Performance attributes, Excitement attributes. When hospitals compete against each other, due to the fact that all hospitals provide similar products and services, customer satisfaction becomes a key differentiation point. With the help of Kano analysis, a hospital will not only be able to identify service attributes that lead to higher levels of patient’s satisfaction, the hospital will be able to classify customers and hence provide patient-oriented approaches. Data Collection Plan - Checksheets Although this method of data collection is simple, it can be a very effective tool for measuring and monitoring efforts in improvements, due to the consistent nature of the method itself. This tool can help a hospital measure the areas that require urgent improvement, by gathering real-time data throughout a period of time. Furthermore, the simplicity of the tool means that implementing this methodology would not cause a much financial burden to the hospital, but by solving the issues, it can reduce variability in procedures. Pareto Charts can also be used to improve hospital processes. The Pareto principle states that, in any group of things contributing towards a mutual effect, comparatively few contributors account for the bulk of impact.

A Pareto chart is a form of bar chart where the variety of contributing factors to an effect on an organization is displayed corresponding to their impact extent. In a hospital’s setting, Pareto charts can be utilized to aid the identification of the vital factors that need the majority of attention. Using Pareto charts will help the hospitals identify and concentrate on elements that provide the most significant impact on healthcare. Value Stream Mapping (VSM) is another tool that can contribute to a hospital in improving the quality of care, by allowing management to map and visualize the flow of information, materials (drugs) and patients. The “value stream” describes all the steps that are necessary to complete a set process, and VSM is often used to reveal wastes, such as patient wait times, to allow for a more streamlined process with minimal disruptions. In addition, VSM can reveal methods of reducing costs and medication wastes, how to save labor expenses and to achieve fiscal responsibility. In the case of this hospital, VSM can be used to map a patient’s course to being treated, including wait time. This tool is heavily reliant on acquiring reliable data regarding the patient’s course of treatment, including the amount of time spent at each stage of the patient. Another tool within Six Sigma that can be utilized in the healthcare industry is the Root Cause Analysis.

Once an event of error has occurred, the first step would be to define the action’s consequences, retrospectively. This is followed by identifying the action and monitoring the causal factors, as well as determining the actual cause to be put through a thorough examination of the event. The principal reason for implementing the RCA approach is that it exposes the cause of errors by looking at factors such as inadequate education or conditions; for instance, not checking on the patient. The use of Statistical Process Control is also an analytical tool used to measure, monitor and control various procedures relating to quality control. Its primary use is to ensure that an entire process is operating as efficiently as possible within an organization. This is a vital technique as it focuses its attention on the idea of detecting problems in advance, hence allowing workers to eliminate or minimize the effect. Contrasting the Root Cause Analysis tool of correcting the problem after it has occurred.

Kano Model

The Kano model of quality is classified into three main categories: Basic attributes, Performance attributes, Excitement attributes. A basic attribute is a minimum quality that is expected and can contribute to customer dissatisfaction when not fulfilled. An example of such within a hospital is the expectation that a physician has the medical knowledge and available medical tools. Performance attributes are qualities that are not absolutely necessary, however, if the qualities exist, it can lead to an increase in customer’s satisfaction. An example of such is a free Wi-Fi service in hospitals. When the basic and performance attributes are satisfied for customers, the hospital can look into excitement attributes, which relate to the surprise element that is not expected by customers, normally seen as an “unspoken fulfillment”. This can be in the form of complementary products such as the offer of a healthy snack in the hospital. This is a way of implementing an excitement attribute, that does not cost the hospital much financial burden, and the fact that it is a healthy snack means that it is more likely to be valued by patients.

The excitement attributes, when implemented correctly in a hospital, can be a feature that offers a unique selling point and helps boost customer satisfaction, which in turn creates a sense of customer loyalty with customers. Owing to this, the hospital should utilize this methodology to improve customer services by creating extra value for customers. Pareto Chart In the case of a hospital, this method can be used to minimize the chance of medications or a patient’s health report not being delivered on-time. The contributing factors can be due to understocked drugs (out of stock), order not processed and read properly, over the congested queue of patients waiting for medicine, long transport time from one end of the hospital to the other and poor communication between departments. The first step would be to rank the causes according to the relative frequency of the cause, from largest to smallest. In this case, the causes could be ranked in descending order of frequency: Over congested queue of patients waiting for medicine, understocked drugs, long transport time from hospital pharmacy to patient, poor communication between departments, order not processed and read properly.

The Pareto principle can then provide insights, for example, 90% of delays come from the overly congested queue of patients. With this knowledge, the hospital will have clarity as to which causes should be tackled with urgency. With the use of Pareto diagrams along with cause and effect analysis (fishbone diagram) or brainstorming, a hospital will be able to reduce the chances of unnecessarily long wait time for patients by allocating resources to improve queue congestion. Furthermore, this tool when used correctly can have an immensely positive impact on customer satisfaction. For instance, the nursing team will be able to put more emphasis on services that provide the most impact. This means customers will be more likely to use the hospital in the future, creating customer loyalty, which has a direct influence on the hospital’s financial performance. Value Stream Mapping A generic path of a patient’s treatment is shown below: Physician > Hospital > Registration > Treatment Approximate wait time between transfers: 30 mins During the entire process, a patient’s time can be broken down into Value Added and Non-Value Added times. The objective of this tool is to minimize, if not eliminate, the existing Non-Value Added time, which is considered to be the time that the patient is not willing to pay for. This can be anything that does not add value to the patient, such as a half an hour waiting time prior to an appointment. That said, although a continuous flow is an ultimate goal, it is rarely possible. Instead, wait times could be minimized by analyzing the VSM to identify areas that require improvement, for example, when a patient has to wait for a long time before a bed becomes available in the hospital. This is very a common issue in hospitals, and it can potentially be reduced by matching the supply and demand for the treatment beds. The duration of wait time for patients requiring treatment beds is a “waste” revealed within the VSM, and a solution for minimizing this is by implementing a “pull” system for transferring patients from one point of care to the next. This solution means that the demand for treatment beds is anticipated by measuring it over time, allowing for an accurate judgment of demand. This means that when a patient requires a treatment bed, it will be ready as soon as the demand occurs, contrasting a “push” system, where a patient has to wait until supply is created.

The VSM method in this situation allows for less waiting time per patient, which improves patients’ perception of the hospital’s services as less time is wasted on Non-Value Added services. Root Cause Analysis RCA tool increases customer satisfaction by being efficient in finding out the cause of a particular problem, which is rather critical to all businesses. In addition to that, being able to identify the challenges that customers are facing also adds value to customers and creates a sense of loyalty between the customer and the organization. In the case of the hospital, RCA can be used to evaluate a pattern of errors, such as mistakes made during an operation, which can be very costly. Because of this tool, a hospital is offered an opportunity to improve the organization’s patient safety and allows the organization to increase its general competency. This tool prevents similar future events from happening, which means less cost due to lower Cost of Poor Quality. The book of “Six Sigma” states that “The basic logic is that a relatively small increase in spending on prevention activities will deliver a more than compensating the reduction in appraisal and failure costs”, (Graeme Knowles, 2011).

Patients who feel that they may have been treated unprofessionally, such as a medical mistake, are likely to impose legal actions against the hospital, which in turn can cost the healthcare organization. Therefore, prevention of poor quality allows an organization to indirectly reduce costs. Statistical Process Control This tool of Six Sigma can be used to discriminate between the changes that improve a hospital process and the changes that do not. This will allow the hospital to put more focus on the crucial aspects that require the most emphasis. For instance, the process of measuring a patient’s blood pressure in a hospital can be measured over time, provide management with an understanding of whether the process itself is predictable with minimal variance in performance or if the process is inconsistent with external factors influencing it. There is an inevitable variability in a patient’s biological processes, however, this tool can solve the imperfections in the measurement process itself by detecting trends in advance, hence preventing a catastrophic error from occurring. Using a control chart along with this process allows a visual representation of management to assess the chart. This is important as the hospital management can identify from the chart, the signals that may be a process is trending towards an issue. This can be used to monitor the effects of Six Sigma on the hospital. With the help of Six Sigma, the hospital should be able to efficiently allocate resources based on the importance of each issue. For example, Physicians at the hospital should not be required to do too much of the work. Instead, by utilizing the resources efficiently, a physician should focus on the diagnosis of patients and provide top-quality patient consulting services. Procedures such as finding the right medicine for the patients and guiding patients to treatment rooms should not be done by Physicians.

Supporting Factors

A factor that is critical to an effective Six Sigma implementation is communication. To ensure that Six Sigma is done well, employees at the hospital should all understand the function and the reason for the carrying it out, essentially creating a top-down management. This helps align worker’s incentives so that they can contribute to helping the organization. Moreover, a strong leadership and along with the availability of resources definitely helps the successful deployment of Six Sigma within the organization. The senior management should be capable of leading the way, with an active and innovative approach. Without this, no matter how good Six Sigma is, it will always produce sub-optimal results. Professionals with “black belts” should be consulted by senior management so that they can be provided with the competent knowledge to guide the rest of the organization.

A master black belt can also increase the success rate of Six Sigma tools, as their responsibility would be to mentor the black belts. The Six Sigma programme can be applied as the tool for improving the processes in hospitals. Whilst it helps the healthcare organization in identifying and eliminating the causes of variability and defects in all operations, it mostly utilizes empirical and other statistical management approaches. With the help of the well-defined DMAIC process utilizing the Kano Model, CheckSheets, Pareto Diagrams, Value Stream Mapping, and Statistical Process Control, healthcare organizations will not only be able to reduce medical errors, they will also be able to minimize the cost of services and increase customer satisfaction.

In addition, an improvement in all the business processes will mean that the employees will be able to offer higher quality services to the patients. If a patient was not taken care of properly within the hospital, the management would identify it as an issue and can then take necessary measures to make advancements regarding that aspect. Bibliography Bisgaard, S. (2009). Solutions to the healthcare quality crisis. Milwaukee, Wis.: ASQ Quality Press.