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Enhance Efficiency and Patient Care

By Jennifer Webster

Patients aren’t widgets, but healthcare organizations can tailor concepts first developed in the manufacturing sector to improve care, efficiency, and patient satisfaction. That’s the message Rochester Institute of Technology (RIT) is taking to those organizations through its Lean Six Sigma Training Program — a program that has already borne fruit at facilities such as Crouse Hospital.

Lean Six Sigma focuses on eliminating waste in systems and practices and on implementing statistical methods to drive breakthrough improvements to an organization’s processes.

Under the auspices of RIT’s John D. Hromi Center for Quality and Applied Statistics, the Lean Six Sigma Training Program offers all levels of learning — from introductory white belt seminars to intensive, 24-day black belt certification. The three-day yellow belt and 12-day green belt programs provide participants with an appreciation of the value of a structured problem solving approach as well as the tools to help a team identify and implement sustainable solutions. These are further supported by training for leadership that helps develop an organizational structure that will sustain lean six sigma.

The Process

The approach is applied - each Lean Six Sigma Green Belt program, for instance, combines training with a project that benefits the client. Over a three- to four-month period — plus additional time for projects to be completed — on-site RIT trainers teach the philosophy, skills and methodology of Lean Six Sigma.

Using the DMAIC (Define, Measure, Analyze, Improve, and Control) problem solving structure, participants learn to set measurable objectives, identify root causes, and ultimately implement solutions that can significantly reduce waste and variability.

“Data analysis is critical throughout the process as it helps to verify hypotheses, identify feasible alternatives, and evaluate ongoing process capability” says Donald Baker, EDD, Executive Director, Center for Quality and Applied Statistics.

A key element of the RIT approach is that lean and six sigma have been fully integrated. Lean, in general, focuses on eliminating waste and decreasing cycle time and Six Sigma is geared toward reducing variability and improving quality.

“A number of components are necessary to sustain a Lean Six Sigma program,” Baker says. “It starts with making sure the leadership is committed to process improvement strategies. Leadership also needs to establish a culture that fosters teamwork, looks at issues from a cross-functional perspective, identifies opportunities for improvement and empowers individuals to work on those initiatives.”

RIT’s training on teamwork teaches individuals to listen to each other and understand the value each person contributes, Baker adds. In a healthcare setting, nurses, physicians, volunteer paramedics and managers might each have a different perspective on an emergency department process issue. As Lean Six Sigma teaches individuals with distinct roles to work collaboratively, each brings different knowledge to the table and has unique solutions to offer, resulting in multidisciplinary synergy. “Physicians often are cited by nurses and others in a hospital as causes of problems, making it critical to get their input into the improvements to be implemented” Baker states.

Creating a Common Language

Part of the Lean Six Sigma approach to problem solving involves creating a shared language that allows issues to be discussed objectively. While the DMAIC framework and many of the concepts and tools originated to improve industrial practices, they can be just as applicable to examine any set of processes, including those in health care, by translating them to the environment of a given workplace or institution. For example, manufacturing’s “lead time” from order to shipment might be equivalent to “length of stay” in health care, says Vincenzo Buonomo, MS, Senior Program Manager, Center for Quality and Applied Statistics.

“In health care, there is an emphasis on patient ‘flow’ just as there would be on flow in a production process,” Buonomo says. “Flow is important to quality, service and patient satisfaction.”

That concept can help healthcare personnel think innovatively about length-of-stay issues and focus on decreasing length of stay without decreasing quality or incurring risks — a balancing process similar to what occurs in manufacturing, Buonomo explains.

“We encourage students to think creatively about solutions, but we also caution them not to jump to conclusions or get attached to one solution too soon,” he says. “Hence the emphasis on the DMAIC approach to understanding the process you are studying — clearly determining where the problem resides, starting to measure, figuring out root causes and devising a more holistic solution to resolve the issue.”

Such careful analysis, Buonomo says, reduces bias in favor of or against certain types of solutions. It also allows participants to avoid pitfalls such as attempting to solve problems they haven’t clearly defined or taking a “firefighting” approach — reacting to crises rather than identifying process issues and working to overcome them.

The Crouse Model

Crouse Hospital began its corporate relationship with RIT in 2010, says Michael R. Jorolemon, DO, EMT-P, FAAEM, FACEP, Senior Quality Officer in the Emergency Medicine Department at Crouse.

“We were having a conversation with our emergency medical services about ways we at Crouse could help them,” Dr. Jorolemon says. “We had Six Sigma black belts here at Crouse and realized the methodology had applicability to health care.”

Starting with yellow belt training, Crouse moved on to partner with RIT and the emergency medical services (EMS) community for a collaborative Lean Six Sigma Green Belt program in 2012 and 2013, assisted by grant funding from Onondaga Community College. Crouse and its partners undertook initiatives in a range of areas, such as emergent cardiac care and medical device improvement.

In the process, the hospital discovered that change in healthcare delivery can be both complex and liberating. One planning group at Crouse was in the early stages of discussing ways to reduce emergency department wait times when disagreement arose. There were initial objections to suggestions that certain processes in the emergency department be reorganized, says Dr. Jorolemon, who was facilitating the discussions. But with input from all groups involved and objective analysis of the ideas presented, resistance to change diminished.

As a result of the discussions, a provider was stationed near the emergency room door to evaluate patients as the triage nurse interviewed them.

“Imaging takes time, so why not see a provider and get that started right up front?” Dr. Jorolemon says. “Once whatever we needed was cooking in the lab, we took the time to put patients through registration.”

The benefit to patients was substantial: Door-to-provider times at Crouse decreased from 76 to 28 minutes as the changes were implemented, and they remain in a control state at 25 minutes. (See related story “Case Study: A Rapid Turnaround” for an additional improvement.)

A Different Philosophy

RIT has a 30-year background in researching and teaching process improvement to diverse organizations. It teaches Lean Six Sigma as a coherent practice, rather than separating Lean’s attention to waste from Six Sigma’s process improvements.

“Given the current issues facing health care in terms of cost reduction and improved efficiencies, combined with the desire to improve patient satisfaction, Lean Six Sigma is ideally situated to assist in achieving those goals,” Baker says. “We look at procedures that cut across the healthcare spectrum, look for waste that occurs in processes and identify strategies to reduce that waste.”

Derrick Suehs, Chief Quality Officer at Crouse, has experienced this change firsthand.

“As a result of Lean Six Sigma, you can have a good conversation about what the real problem is,” he says. “Often, people express opinion as if it were fact. It helps to create an environment in which you can have a diverse dialogue focused on solving a particular problem. In a setting with limited resources, it helps you allocate resources better, which is a service to the entire community.”

With Lean Six Sigma, dialogue, processed through disciplined methodology, leads to measurable change. Crouse Hospital relies on statistical methodology to ensure that changes are genuine improvements.

“We track control — not all hospitals do this — at a 95 percent confidence level,” Suehs says. “We apply statistical process control to our efforts so we know the change was real.”

The change is also cost-effective, says Buonomo.

“The results of Lean Six Sigma are achievable in any healthcare organization,” he says. “It takes some planning, time and investment, but the benefits outweigh the costs.”

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