Draft Simplifying Process Improvement/Lean/Six Sigma Programs for Healthcare Craig A. Stevens, MBB, PMP, ACS
In the words of Dr. Deming, “A bad system will beat a good person every time.�
Abstract and Key Objectives of the Paper and Presentation: The biggest problem with many of the process improvement programs is that you have to have a degree in statistics or engineering to understand them - Not so with our process improvement program. We focused on three easy to grasp phases: Assessment, Problem Solving, and Implementation. In this paper, we will walk through a three-phase process that incorporates the concepts of continuous improvement, Lean, Six Sigma, a little common sense, and TQM described by the Westbrook Stevens seven attributes of excellent management found in the book Geronimo Stone written by me. See how we apply an approach to Continuous process Improvement (CPI) using the framework of a Total Quality Management (TQM) Approach applied with Lean, Six Sigma, and Strategic Project Management (SPM) tools. Learn how we simplify CPI using three easy to understand phases - Assessment Phase, Problem Solving Phase, and Implementation Phase. Learn our framework for a sustainable program using the Westbrook Stevens Mobile of the Seven Attributes of Excellent Management: 1. Build Excellent Leaders and Empower Practitioners; 2. Develop an Excellent Culture of Commitment to Process Improvement; 3. Ensure an Excellent Customer Focus; 4. Motivate People and Build Excellent Improvement Teams; 5. Build Excellent Core Competencies and Skills in Problem Solving and CPI tools (Lean, Six Sigma, SPM, etc.); 6. Apply Excellent Change Management and CPI to Systems and Processes; and 7. Use the seven steps of excellent Performance Measures in each of the three phases. See how we apply all of the above to our 600 Healthcare Practices (Doctor Offices).
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Draft INTRODUCTION: Environment and Background: In a doctor’s office, revenue comes from the healthcare providers spending time with the patients or from other nurse or medical technician providing clinical services such as X-rays or ultrasounds. If we could just magically eliminate all other processes and cost, we could maximize our profit and maybe even serve the patient better. If only the patients could magically lineup for the doctor to see, spend no time waiting, get perfect service, and pay with cash without any other staff or systems involved. That would minimize cost and maximize profit and service. However, the world is not that simple. Systems and processes have to be developed to bring patients in, ensure the quality and safety of all involved, maximize the patient satisfaction with the experience, bill and collect for services, clean and maintain facilities and equipment, track medical conditions and records, surf the growing waves of regulations, manage risks, manage people, provide space, communicate, etc. Therefore, we need systems and processes to pull everything together for the doctors to serve the patients. These business processes make everything else possible. In addition, Healthcare businesses like all other business have life cycles. Each life cycle has different requirements for improvement. However, most process improvement (PI) programs never consider this. Engineers should consider improvement opportunities not like cooks strictly following cookbook recipes, but rather as chiefs challenging recipes and optimizing favors. For example: New emerging practices struggling for survival require an entrepreneurial approach to lean and process improvement. Building systems too quickly takes attention away from doing real work and will increase the risk of bankruptcy. Many a bankrupted company had great systems to play with but never served the customers well. Growing practices require a systems engineering and development approach and a focus on slashing cost and staff will damage growth and limit revenue. Page 2
Draft Well-established practices can take a full PI approach and should focus on a strategy of optimization along with creating and spinning off new ideas for expanding markets. However, these new ideas are intra-preneurial in nature. Therefore, be careful of over doing error minimization (six sigma, zero defects). That could also limit creativity and increase stress and the risk abandoning good ideas too early. Declining practices requires an opportunistic approach for mergers and divestitures or for looking for other opportunities. Cost savings, lean, and minimization become survival tactics.
The Healthcare Problem to Solve: What do you really want your doctor to send time on? Likely, the answer is “medical acumen as applied to your medical needs.� Therefore, others usually focus on the business of practice management, which allows the doctor and other medical personnel to focus on high quality medical services. Nevertheless, the medical staff makes up the senior stakeholders and the revenue engines. The senior medical staff is the only revenue generator and has the most to gain or lose and will likely have a high degree of interest in the operations of the business. The dichotomy becomes this - to maximize the revenue the doctors must maximize concentration on medicine and are usually too busy to participate in the routine business part of medicine. However, to minimize efficiencies, lower cost, and provide the systems and process to see patients, someone has to optimize the operational business part of medicine. Therefore, a practice management staff has to do that. Over staff and you may have smoother operations but you also have lower profits and possibly an unsustainable business model. Too little staff and your revenue may drop as patients find more service oriented practices, which may also lead to an unsustainable business model. The medical office world is very competitive and the practice management staff is often highly stressed. Therefore, we owe it to our customers, teammates, and staff to continuously improve our systems and processes to better serve our customers and simplify our work. The
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Draft question then becomes - How can we do that in a simple way so that the medical and office staff can focus on their primary jobs? Creating a Systematic and Repeatable Way to Improve: The two words, “Systematic and Repeatable” are the key to excellence in operations. Furthermore ensuring that operations are systematic and repeatable is one of the key goals of every audit. Whatever we create has to be systematic – meaning smart people use their expertise to develop the optimal programs and systems that they applied to their operations. Repeatable means, whoever uses the systems can apply the same rules and have similar success. This is especially true in large organizations. In our case, we want to apply simple systematic and repeatable improvement tools in a busy medical service environment so that our many practices can all have similar positive results. Size of the Problem: We have many (about 600) similar but different islands of independent revenue and cost centers of different sizes (1 doc to 200), with over 10 different medical specialties, in different markets across the U.S, with different levels of resources. Different managers and senior staff with different interest run each of the practices. Although everyone is a knowledge worker, very few understand statistics or higher-level mathematics and no one has the desire or time to spend on complicated techniques. Our centralized Continuous Process Improvement team is small and may only be able to reach 1/30th of the practices in a single year. Therefore, we have to develop systematic and repeatable systems that practice managers and their staff can use, supported by our small CPI Program (CPIp) team, and augmented with third party vendors as needed. The rest of this paper talks about the program we developed.
A SYSTEMS APPROACH TO CONTINUOUS IMPROVEMENT: We decided to take a unique approach to Continuous Improvement using a specific Total Quality Management (TQM) Approach, Three Phases of Problem Solving, Three Types of Support, and Five Levels of Lean Six Sigma Training.
A Total Quality Management Approach: Page 4
Draft Throughout my career as a consultant, I spent a couple dozen years taking graduate level courses leading to PhD’s but with a different purpose, to learn as much as I could about business and operations. During this time, my first dissertation attempt focused on defining a model for TQM that everyone could understand and implement successfully. As the popularity of TQM died, the model that we developed became the seven attributes of the Mobile of Excellent Management and the subject of the first Geronimo Stone book: 1. Growing Excellent Leaders, 2. Building an Excellent Working Culture, 3. Focusing on Excellent Customer Service, 4. Building Excellent Teams of Empowered People, 5. Mastering Skills, Problem Solving, and Core Competencies, 6. Mastering Change and Continuously Improving Methods, Systems, and Processes, and 7. Driving Toward Excellence by Measuring Performance.
As a mobile requires perfect balance, so too, does Excellent Management within an organization or project. Master this and you can improve any operation. On a mobile, remove any one piece and the system is out of balance. Likewise, remove any one of these seven attributes within an organization and the management of the organization or project is out of balance. Also, as on a mobile, in an organization or project, no one attribute will work alone. For example, one cannot just continuously improve. That requires addressing leadership commitment, removing organizational culture barriers, focusing on the value added for the customers, motivating the teams doing the work, teaching the tools to the people doing the work, and measuring performance (before, during, and after) to understand the results. Each of the seven attributes represents major concepts in management theory and process improvement and chronological order is important. You therefore need to address the seven attributes in order (1-7, as listed above). We use the seven attributes of excellent management as the foundation for approaching continuous improvement.
Three Easy To Understand Phases for Process Improvement:
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Draft Continuous improvement is the sixth attribute of excellent management and it explains mastering changes to processes and systems as a way to serve our customers better (before our competitors do). We “either master change or become irrelevant.” Either we continuously improve the things we do and produce or we limit our potential, lose market share, and eventually lose our company and our jobs. There are many programs with many different steps designed to improve processes, quality, and operations. However, we can simplify all of them by thinking of only three phases. In general, once we select a process to improve, a process improvement exercise can be thought of as having only three important and necessary phases: 1) The Assessment Phase, 2) Problem Solving Phase, and 3) Implementation Phase.
Like the pyramid pictured here, assessments take the least amount of work, the problem solving takes a little more effort and skill, and the implementation may take a great deal of effort.
Understanding the Assessment Phase = (Six Sigma’s DMAIC - Define, Measure, and Analyze Steps): “Problem Solving” is “Continuous Improvement.” However, problem solving comes after assessments, therefore a mistake that many people make is to jump to problem solving before they understand the problems. An Assessment Phase has two sub-phases, Collecting and Analyzing Information. We use the seven attributes of excellent management as the framework for collecting information. In every case, we define excellence for each one of the attributes, compare how we are currently addressing each attribute, and find the gaps between what we should be doing and what we are doing.
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Draft In a perfect world, the ones implementing a change are also involved in assessing the need for the change. During the assessment phase, the goal is to find both “good” systems and processes to highlight and “bad” ones to improve. Therefore, an easy way to communicate this effort is by symbolically planting red and green flags. We plant the red flags on the problems needing improvement and the green flags on the best practices to share with others. Green flags become a symbolic motivational award for doing good work. Red flagging is not a new idea. Often during engineering audits, the engineer would attach a red tag to a problem found on a factory floor. This may have been a piece of equipment dripping oil or a safety violation. These red tags became known as flagging problems. Once, during a pre-tiger team GAO type audit, my escort told people that he held out his hand to shake my hand and I put three red flags on his arm. It is important to stress to everyone connected to the assessment that the only goal of this phase is to plant the flags, not solve the problems. Therefore, the first part of an assessment focuses on just gathering data, from: The people doing the work, suppliers, customer, patients, and others, The gatekeepers of knowledge or those tracking the technologies within our organization or externally, Key metrics we record, Observations, etc.
After collecting or gathering data, comes the evaluation or analysis. Chances are we have planted many more red flags than we have resources to solve. The analysis part helps us decide on which red flags to bring forward. During the analysis step, we ask the questions that reveal the truth behind possible red or green flags.
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Draft The Problem Solving Phase (also overlaps DMAIC’s Define, Measure, and Analyze Steps): The goal of the problem-solving phase is to find, not implement, the most valuable solutions. To do this we focus on root causes and making decisions on how to improve. In the words of Anthony J. D'Angelo, “When solving problems, dig at the roots instead of just hacking at the leaves.” Like selecting the problem to solve, we also look for the biggest-bang-for-the-buck solutions to root causes. The question becomes - Where can we make the biggest positive impact with the lease disruption and expense? However, even with all the facts, people do not usually make decisions based on the facts. People usually make decision based on how those facts make them feel. Therefore, it is best to involve those who have to implement the solutions in the problem solving efforts. They are the ones who live with the “improved” operations. The five Steps to Problem Solving: As we divided the Assessment Phase into the two steps of collecting and analyzing information, we also divide the Problem Solving Phase into steps. Problem solving efforts start in the same way as the assessment did, by collecting and analyzing additional problem specific data. The goal is to understand the selected problems better and to prepare for finding appropriate solutions to implement. The purpose of the problem-solving phase is to find a final logical solution that will solve a problem or improve a current process or system. Typically, our problem-solving exercises have several logical chronological steps as explain here. Step 1 – Problem Selection(s) – Chances are we do not have the resources to solve every problem we can find. Therefore, before we can solve a specific problem, we must first select the problem to solve. This becomes the first step in problem solving. Similar to Project Portfolio Management, we develop problem portfolios with the goal of selecting the biggest bang for the buck candidates for improvement. We prioritize the red-flagged candidates with that in mind. In addition, we also look for the biggest impact green flags or best practices so we can share these ideas with others. In
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Draft the words of Abraham Lincoln, “I shall try to correct errors when shown to be errors, and I shall adopt new views as fast as they appear to be true views.” Step 2 – Planning for Problem Solving Efforts - Once we have the problems selected and prioritized, then planning becomes important. Treat the problem solving efforts as a project to manage and plan for resources (right people and expertise), space, time, and other needs to start solving the list of problems. Step 3 – Preparation and Defining the Selected Problem(s) - In the words of John Dewey (an American Educator and Philosopher), “A problem well stated is a problem half solved.” One thing that all problem-solving systems should have in common is the phrase, “Define the Problem.” Step 4 – Idea Generation Cycle - “The best way to get a good idea is to get a lot of ideas.” By Linus Pauling American Chemist. Once we identify and define a specific problem, the team can start the idea cycle. Think of an idea generation cycle as more than just brainstorming. Brainstorming often works for simpler problems or to generate ideas to test, but sometimes the problems are complicated and require more effort and engineering to solve. Therefore, we brainstorm and allow time for the idea to incubate. Study the problem to building understanding, let it incubate, and continue until we find a solution or we abandon the problem. Often, what scientist often call the “eureka moment” comes after a great deal of study and during a time of rest. Therefore, do not be hesitant of taking an incubation break for the best solutions. It is better to be right than fast, in the words of Peter Senge, “Today’s problems come from yesterday’s solutions.” However, a continuous improvement mindset also means, that every excellent solution will one day be someone’s status quo to improve.
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Draft Step 5 – Problem Solution Evaluation Funnel - Once the ideas for solutions are collected, the next steps are to consolidate and evaluate the best ideas with the goal to drive to the final solution. Therefore, the goal of the evaluation step is to drive our efforts to a signal SMART solution (A Specific, Measurable, Agreed On, Reasonable, and Timely Solution). We can think of this step as a funneling effort with three steps: 1. Narrow to the Few Best Possible Ideas/Solutions, 2. Evaluate the Best Solutions (Based on Root-Causes, return of investment, etc.), and 3. Narrow the Few Best Solutions to a Final SMART Solution.
The Implementation Phase = (DMAIC’s Implement and Control Steps): Many times all three phases of the process improvement efforts overlap. Even during the implementation phase, we may find that we need additional information or we require additional problem solving efforts. Every solution brings with it a change but no company can afford to implement every desired change at one time. Therefore, not only do we prioritize the problems to solve during the Problem Solving Phase, we also prioritize the solutions and decide which changes to implement. Selecting the solution to implement requires a project portfolio management approach. Once we decide on the final solution, the next process improvement phase relates to implementing the changes. Simple changes require very little effort; however, the number one tool for implementing a complicated change is project management. Nevertheless, we can simplify every implementation of a solution by thinking in terms of four “generic “project management phases. Every project lifecycle have these four generic phases in common, if only by concept and not by name. 1. Project Conceptual Design Phase – Answer the questions, “What are we trying to do? What does good look like?” 2. Project Planning Phase – Answer the questions related to “How are we going to reach that picture of good?” Page 10
Draft 3. Project Implementation Phase – Do the work, which is required to make the plan happen. 4. Project Transition Phase – Is where we transfer the fruits of the project teams’ labor to the people who will operate the improved processes/systems.
Three Levels of Support: “Quality is everyone’s job,” This is one of the first lessons of the quality movement. As the quality movement grew, mature organizations found they had to build core competencies and empower as many people as possible just to compete in the global market. In the word of Victor Dinkus (Quality Manager at Tennessee Eastman in the 90’s), “We use to have 14000 people and only 400 were paid to think. Our goal is to have 14000 people paid to think.” Therefore, being a very small process improvement support group in a large organization we developed three levels of support:
1. Level One – Self Directed Improvement for the practice managers and their staff. 2. Level Two – Internally supported process improvement using the CPIp team. 3. Level Three – Third Party Directed Improvement to address the more complicated or politically charged problems.
Level One - Self-Directed Improvement: The first level is the largest and broadest! It is likely that our small team could not visit more than 3% of all the practices within one year. Therefore, one of our primary roles would have to be evangelizing continuous improvement and equipping the practice managers’ staffs with the tools to do self-assessments.
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Draft These assessments would have to be Practice Manager Driven and virtually supported by the CPIp Team. Therefore, the CPIp team would have to develop training that is stored online along with real-time Web-based workshops. Similar to Six Sigma type programs, this training must be systematic and repeatable with different levels of training for different levels of involvement and expertise. The last section will explain our training program and touch on the tools. Level Two – CPIp Team Facilitated Improvement: Unlike the larger group that includes all the Practice Managers and their staff, the CPIp team is much smaller but professionally trained management engineers focusing only on process improvement. These internal consultants support the program. The role of the practice managers is to focus on daily operations, where the role of the CPIp team focuses on short-term support to the operations. Our job is to go into the practices and help solve often very specific problems. As in this picture of the triangle, the practice managers work increases from assessments, to problem solving, and then implementation of changes into operations. Our CPIp team’s focus in mainly in the assessments, then in facilitating the problem solving efforts, and only in supporting the planning for implementation.
Third Party Facilitated Improvement: Since the CPIp team is very small, there are times when a found problem might take more time to solve than the CPIp team has. Likewise, there may be politically changed problems where it makes more sense to bring in a third party consulting group. The consulting group would work directly with the practice management staff and only be directed by or supported by the CPIp team as needed.
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Draft Five Levels of Lean Six Sigma Training: To make the program work and to empower the practice management staff required us to develop a well thought-out systematic and repeatable training program with many resources: On-line Tool Box with a Menu of Tools and Triggers for When to Use the Tools, o
General Assessing, Problem Solving, and Implementation Tools
Online 15 Minute Audios with PowerPoint Presentation, WebEx type Training, Web Pages and SharePoint Sites, Newsletters and Email Communications, Example Projects for Highly Repeatable Processes such as: o
Scheduling Templates,
o
Staffing and Labor Management,
o
Patient Flow,
o
Telephones Systems,
o
No-Show Rates,
o
Room Utilization
Lessons Learned and Materials (Best Practices, Green Flag Reports) Other Organizational Support Development Building a Culture of Continuous Improvement Obtaining other Resources for Improvement and Sustainability
To train people how to use all the resources we developed, we set up 5 levels of training similar to traditional six sigma training. Each level of training would focus on parts of the Mobile of Excellent Management as a framework to apply the appropriate level of Lean and Six Sigma tools with Lesson Learned. Therefore, we developed five levels of training.
Level 1 - 30 Minute Orientation: The 30-minute orientation comes in both thirty-minutes and one-hour sizes. The smaller 30-minute training is for those who plan to continue the Page 13
Draft training and dive deeper into the concepts of Continuous Process Improvement. The longer program is for the leadership who want just a high-level overview.
Level 2 – Two-Hour Whit Belt Training – The two-hour training is also designed with leaders in mind. However, it is also the first step for those wanting more details also. The focus is on empowering people and building a culture of improvement. During this two hour training, the participates focus on the steps of empowerment and situational leadership along with some cultural issues of making improvements happen. They will also learn about the other attributes required for excellence.
Level 3 - One Day Yellow Belt Training – During this stage of training, focus on what the Practice Managers should know about improving their practices. Here we focus on the biggest rocks and Lean concepts, which are the easiest concepts to learn. Lean is a descriptive word to define a
concept not an acronym of acrostic. “Lean” or remove waste and operate in a “lean way” is the
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Draft concept and there are some very specific lean tools. The biggest rocks are those processes that every practice can master to have the biggest return on investment: Scheduling Templates, Staffing and Labor Management, Patient Flow, Telephones Systems, No-Show Rates, Room Utilization
Most of the Yellow Belt efforts focus on learning the tools of Continuous Process Improvement, applying them to the biggest rocks, and learning the general concepts and specific tools associated with lean.
Level 4 - Four Day Green Belt Training and Project: The Green Belt Training is for those interested in becoming process improvement practitioners. It is a deeper dive into the Six Sigma tools and project management techniques. During these workshops, the focus is mainly on tools along with getting results and implementing changes. For each of the other levels, Page 15
Draft people may chose which workshops to take and they do not have to decide to take all the course work required to obtain the ranking of White Belt or Yellow Belt. Each workshop is complete and stands along. However, each of the earlier levels are prerequisites for the green belt. Therefore, the more complicated green belt subjects require people to have finished the earlier belts. Also during the green belt training, a project is required. The focus of the Green Belt Training is on Tools.
Level 5 - Six Month Black Belt Mentoring Program: All the other levels of training are prerequisite for the Black Belt Training. The Black Belt training is reserved for the CPIp Team and those who will be supporting the team with the cross-practice improvement program. The focus of the Black Belt Program is to learn facilitation and is a train-the-trainer type program. The additional information one learn during this level is Traditional Systems Engineering (System Thinking). Page 16
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Draft Speaker: Craig A. Stevens, PMP, ACS http://www.linkedin.com/in/craigastevens http://www.llumina.com/store/geronimostone2.htm http://issuu.com/craigastevens/docs/2013_february_art_catalog_-_craig_a._stevens
Craig Stevens has been a Management, Industrial, and Systems Engineer for over 30 years. Currently he is the Manager for the Process Improvement Program for HCA Physician Services, where the CIPp Team is developing the CPI/Lean/Six Sigma program for about 600 practices. He is also the president of Westbrook Stevens, LLC; an Author; and a Visual Artist. Before HCA, he worked as a consultant for over 100 different organizations in 25 states including (US DOD, US DOE, NASA, Lockheed Martin, Westinghouse, DuPont, etc.). Craig has worked in every layer of an organization and in several industries (Healthcare, Government, Manufacturing, Agriculture, Hospitality, Scientific Research, Energy, Waste Management and Environmental Restoration, Not-For-Profits, and Construction). He was the Chief Engineer and Quality Manager for PRAGMATICS, INC. (8a), Program Manager for Science Applications International Corporation (SAIC), and was the Mechanical Engineer SME in solar and electric power, explosives, and general engineering for U.S. DOE, Office of Scientific, and Technical Information (OSTI). Craig is the Author of the Geronimo Stone series and is writing a book on Strategic Project Management for Gower Publishing in London. Currently he teaches Project Management and Business Analysis at Belmont University and has written many papers on management subjects and served as adjunct faculty for Vanderbilt University, Belmont University, Trevecca Nazarene University, University of Phoenix, Nashville State Tech, and UT Knoxville as a TA. He was also a trainer/facilitator of Project Management for the American Management Association International (AMAI) and Padgett Thompson. He has taught graduate and undergraduate classes and workshops in Strategic Implementation, Innovation and R&D, Operations Page 19
Draft Management, Project Management, Change Management, Manufacturing Management, Strategic Management, General Management Principles, Systems Management, Statistics, Customer Service, Engineering Economy, and Human Factors Engineering.
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