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One Size Fits All? A Case for the Improvement Science Approach Journal of the Society for Healthcare Improvement Professionals © 2013

515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-‐213-‐538-‐0700 • [email protected]

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One Size Fits All? A Case for the Improvement Science Approach

Nancy Riebling, MS, PMP, MT (ASCP)

Adrin Mammen, MS, MBA, FACHE

Summary

A New Organization

Healthcare professionals are faced with many challenges in a complex healthcare delivery system. Cost, quality and access, the three components of the “iron triangle,” need to be managed effectively to achieve optimum care, or an equilibrium state. Healthcare organizations (HCOs) spend millions of dollars

every year on consultants to help them analyze and enhance their performance to help find this equilibrium. HCOs have traditionally maintained the operations, quality and financial management

functions separately. There are many approaches that can help optimize performance and no one process methodology solves the needs of a complex healthcare organization.

Fortunately, managers throughout the North Shore-‐LIJ Health System (NSLIJ) no longer need to look to the outside and they can avoid expenses that come with hiring consultants. They can turn to the Center

for Learning & Innovation (CLI) to learn how to implement various operational performance solutions. CLI is the system’s corporate university. Its role is to provide education aligned with the evolving strategic vision of the health system. Courses offered include, clinical skills, enrichment, improvement

sciences, patient safety and simulation. The Applied Leadership Effectiveness and Development Program offers executive-‐level education to physicians and operations leadership to enhance professional growth and development. Managers send their teams to CLI to learn a variety of process improvement

methodologies, bringing these techniques and concepts back to their worksite for implementation. The Operational Performance Solution Team (OPS) is one arm of the corporate university. They are responsible for teaching improvement science methodologies and mentoring projects. The team is

comprised of health system employees with diverse backgrounds (e.g., industrial engineering, IT, laboratory, and nursing) trained and certified in the improvement science methodologies. The OPS team plays a unique role in driving successful change throughout NSLIJ, improves customer and employee

satisfaction and enhances the overall organizational performance in the operations, quality and financial management functions.

Through the health system, the strategic goals cascade down to action plans and corresponding metrics. These goals are illustrated in a diagram called “The Dashboard.” It depicts the eight organizational goals

as dials of a car dashboard and metaphorically demonstrates that if one dial in a car is not operating properly, the car as a whole will not run as intended. The same is true with the organization’s goals



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– if one goal is not being met, the organization will not operate as intended. The eight organizational goals are Financial Performance, Quality, Patient Experience, Employee Investment, Community Benefit,

Market Growth, and Teaching and Research. Additionally, Physician Partnership is driven by these eight goals. Metrics for the strategic goals are shared using a balanced scorecard approach. While the scorcard provides a framework for measuring and assessing performance, it does not provide a solution

or strategy for overcoming the organization’s operations, quality and financial management challenges.

The approach by NSLIJ to overcome these challenges is through a variety of performance improvement methodologies. Whenever people speak of many of these methodologies it is in the context of a project. By definition a project is a temporary endeavor undertaken to create a unique product, service or result.

The temporary nature of projects indicates a definite beginning and end (PMBOK 2008) [1}. The issue, time frame and goals drive the choice of methodology for the project.



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(Diagram 1). FTD Lean Capstone Six Sigma

Issues

How Much Time Is Needed 1 day < 30 days 6-‐8 weeks 4-‐6 months

Excessive Waste X X

Need to Increase Flexibility X

Data Available X X X

Data Needs to be Collected X X

Chronic Issue X X X

Long Cycle Times X X X

Excessive Process Defects X X

Excessive Motion X

Excess Inventory X

Need to Increase Capacity X X X X

Multidisciplinary Team Available X X

Complex Problem X

Multiple Step Process X X X

Excessive or Hidden Rework X X

Excessive Process Variation X

Asses Value-‐added Activities X

Excessive Bureaucracy X X X

Rapid Implementation Needed X X

Know Current Process Capability X

Long-‐Term Control Mechanism X X



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© 2006 The Center for Learning & Innovation

The methodologies are collectively called improvement sciences. Across the improvement sciences, there are many overlapping tools. No one methodology addresses every issue in a complex healthcare

environment. The OPS team members are highly skilled with change management and technical expertise in the improvement sciences. Quality improvement is part of every employee’s responsibility. The OPS team guides and coaches employees throughout the health system to overcome challenges or

issues. The OPS team is cross-‐trained in a variety of methodologies including: Six Sigma, Lean, Clinical Microsystems, Fast-‐Track Decision Making, Capstone Project Management, Simulation, and Facilitation.

Below is a description of the various improvement science methodologies that are utilized at NSLIJ and

an example of a project using each methodology.



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Six Sigma

The Six Sigma is a highly robust process improvement methodology that focuses on customer requirements and the measurement system. It enables healthcare providers to measure how many

errors or defects occur in the existing processes. During a six sigma project, a systematic approach is utilized to reduce or eliminate the causes for the defects, getting as close to “zero defects” as possible. The methodology consists of five phases, Define-‐Measure-‐Analyze-‐Improve-‐Control, where key activities

aid in the problem solving. These benefits are eventually seen by patients in terms of lower costs and enhanced services.

Example: Issues like handoff communication which cross multiple disciplines within the organization benefit from the use of the Six Sigma methodology because a hand-‐off is a transfer and acceptance of

patient care responsibility achieved through effective communication. In medicine, wide variation exists in handoffs of hospitalized patients from one physician or team to another. Measurement system analysis was critical before we begin comparing the current handoff processes. One of the first issues the

team tackled is how to define an appropriate handoff. In the measure phase, videos of various handoff communication scenarios were created by the Patient Safety Institute portraying physician-‐to-‐physician and RN-‐to-‐RN handoffs. Clinical staff was asked to rate the handoffs for seven key deliverables (relevant

information, diagnosis/procedure, current status, recent changes, concerns, plan of care and unresolved issues) on two separate occasions. Reproducibility and repeatability was found to be lacking. Operational definitions needed to be developed and refined so that the variation came from the process not the

measurement system. Too many times in healthcare the variation comes from the way we measure. Once the measurement system was improved, the analysis demonstrated senders and receivers had statistically differing perceptions for all seven key elements. The improvement strategy focus was on

creating the common template between sender and receiver on what constituted an appropriate handoff. After the improvements were implemented in the control phase, the video measurement system analysis showed an improvement in reproducibility and repeatability. Moreover, there was no

statistically significant difference in how senders and receivers rated handoffs.

Lean

The Lean methodology takes its name from the concepts of “eliminating waste.” Flow and delay times are analyzed for each activity within a process. A distinction is made between “value-‐added steps” and “non-‐value-‐added steps.” Utilizing an approach called “Kaizen,” the Japanese term for continuous

improvement, employees work together and learn by doing as they apply structured improvement methods and monitor results on a targeted process ensuring that the “value-‐added” steps are done efficiently.

The Head & Neck Radiotherapy Process of Care is a 180-‐step oncology process from consultation to

treatment involving eight physician specialties, four allied health professionals, two registered nurses and three patient service professionals enabled them to increase their capacity by 150% and decrease their turn-‐around time by two days by developing a swim lane diagram looking at the value-‐stream and



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identifying waste. Not one individual before the Kaizen understood the entire process and the impact of their role on the process downstream.

Clinical Microsystem Approach

The Clinical Microsystem is the small, functional frontline units that provide most healthcare to people.

They are the place where patients, families and care teams meet. Microsystems are the essential building blocks of larger organizations and of the health system. The 5 P’s framework (Purpose, Patients, Professionals, Processes, and Patterns) can be thought of as a structured method of inquiring into the

anatomy of clinical microsystem (Nelson 2007). Rapid cycles of change can be tested on a small scale and then replicated.

Adverse drug events and near miss medication errors are under-‐reported in healthcare (IHI.org). Many healthcare professionals associate incident reporting with a punitive process. By utilizing a microsystem

team at the bedside with rapid cycles of change, the team was able to go from three separate reporting tools to the creation of one standardized electronic form in a short period of time. The structure of the modified form included verbiage that welcomed anonymity, encouraged reporting and created a culture

of trust between the different disciplines on the unit. Through this approach, front-‐line employees were engaged in their role in patient safety.

Fast-‐Track Decision Making

Fast-‐Track Decision Making sessions are run by change facilitators and staffed by employees. The team utilizes team-‐based problem-‐solving to resolve issues, improve processes and empower staff to seek

management support for change. The team is accountable to their leadership for implementation and follow-‐up action plans. Through this approach, management develops innovative ways of doing business by implementing the recommended changes. Skills like brainstorming, affinitizing, categorizing and

development of action plans are incorporated to provide a structured approach to problem solving. These same skills are incorporated into initiatives utilizing other methodologies such as Six Sigma, Lean or microsystem.

While working on a Six Sigma project, movement of specimens within the laboratory was a heartburn

issue of the staff uncovered by the team which was not within the scope of the project. Fast-‐Tracking Decision Making was esed to address this issue at the Core Lab, the NSLIJ reference laboratory that processes over eight million specimens a year. Specimens were being misplaced when they were

transported from the accessioning department (nontechnical registration) to the laboratory clinical departments creating additional work for staff in both areas. A team of laboratory personnel designed color-‐coated pocket guides of laboratory tests and created matching signs to aide non-‐clinical staff in the

delivery of specimens to the appropriate clinical location.



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Capstone Projects

Capstone Projects are incorporated in the ALEAD leadership development program. During the ALEAD program, employees take a course on key process improvement tools. Employees are placed into teams

or create their own team. Each team is encouraged to identify a process improvement project that aligns with the health system’s strategic goals. Capstone projects are intended to be intensive, active learning projects requiring considerable effort in the planning and implementation of solutions.

Employees are expected to present their work in written and oral formats to senior leadership.

A capstone project was done in hospice to address a regulatory change. A New York State law went into effect that physicians must discuss and document palliative care with terminally ill patients.

The team designed brochures for patients and physicians, held open houses and presented at the medical board. As a result of the capstone team’s improvements, there was an increase in hospice admissions

from 9.4% to 15%, a decrease in days from referral to admission from six to four days, and an increased length of stay on hospice service from 5.45 days to 8.5 days.

Simulation

Many fortune 500 companies and government agencies are using simulation to improve productivity. By modeling the processes, teams can understand how a process functions and see how it changes under

different conditions. Since these hypotheses can be tested with minimal time compared to the actual task, optimal solutions can be identified for complicated processes.

The first simulation project done at NSLIJ focused on the emergency department. Emergency departments around the world have been tackling the issue of overcrowding for decades. The simulation

has a backend database that was populated with historical data on performance for different aspects of operations such as triage, registration, laboratory and radiology. The simulation is capable of predicting the effects of various changes to the model such as staffing, flow of arrivals and disposition of patients.

Improvement sciences help meet challenges within the operations, quality and financial management

functions. That ability lies in the HCO’s ability to align projects to the strategic goals of the organization and the ability to prioritize relevant projects utilizing the most appropriate methodology.

• Six Sigma: Decrease the variation and remove the defects (when we do not meet the customer expectations)

• Lean: Remove “waste” or non-‐value steps from the proces • Microsystem: Rapid cycles of change (PDSA) at the microsystem level • Fast Track Decision Making: Empower the staff to identify solutions to issues

• Capstone Project Management: Apply lessons learned to solve an issu • Simulation: Testing scenarios to improve flow or productivity



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There is no magic bullet or one size fits all method. Many organizations feel the need to pick one method instead of taking tenants of each of the methodologies and applying them to the problem at

hand. The key is to follow a structured approach, engage all employees and utilize data to monitor the changes. The role of the OPS team is to assist with the selection of the proper methodology and mentor the teams with the tools.

References

A Guide to the Project Management Body of Knowledge (PMBOK Guide). Newtown Square, PA: Project

Management Institute, 2008. Print.

Percent of Admissions with an Adverse Drug Event. Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Measures/PercentofAdmissionswithanAdverseDrugEvent.aspx. Nelson, Eugene C. "Practice-‐Based Learning and Improvement." (n.d.): 2007 Print.

[1] Project Management Body of Knowledge, by the Project Management Institute.

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