Instructor: Hi everyone.
In this lecture, we're going to be continuing discussing
process design and continuous
quality improvement in healthcare.
So to continue, we mentioned Six Sigma and Lean
in the last lecture, and they are two tools
or methodologies that are often used in quality improvement.
They're helpful in improving patient outcomes.
The application of these methodologies in the healthcare
industry is driven in large part by the successes
of these two methodologies in the manufacturing industry.
As you've seen oftentimes throughout this lecture,
a lot of the tools and practices used in healthcare
quality improvement were initially developed
in manufacturing, and it bear many similarities
to any production or industrial process.
This is also, these have also been taken up
and used more often,
because there's been a greater emphasis on quality
of care in healthcare than there has been in the past.
For example, in the United States,
hospitals can receive additional payments from the sector
for Medicare and Medicaid services or the CMS,
if they improve patient satisfaction
and lower readmission rates among patients
with certain medical conditions.
Therefore, healthcare organizations are very motivated
to improve patient outcomes.
So to begin with, Six Sigma is a quality improvement
methodology that was developed at the Motorola Corporation
in the 1980s that emphasizes the elimination
of variation in error.
How does it work?
So it uses Sigma levels to reflect the total number
of defects per million opportunities.
The higher the Sigma level, the lower the number of defects.
The goal of Six Sigma is to reduce the rate of defects
to a Six Sigma level
or 3.4 defects per million opportunities.
As we know, if you've studied statistics before,
Sigma is a symbol for standard deviation,
and the name Six Sigma reflects the goal
of having process outputs within a span
of six standard deviations, or the mean plus or minus
three standard deviations.
Six Sigma projects in healthcare settings can help reduce
waiting times and delays, prevent adverse effects,
lower costs, and improve other patient outcomes.
Not noted here.
This reflects not only an approach
for quality improvement,
but also a key part of quality improvement philosophy.
The cornerstone of Six Sigma is process management
through the DMAIC cycle,
and DMAIC is called that
because it stands for five phases.
Define, measure, analyze,
improve, and control.
And again, this chapter loves these lengthy
and wordy charts,
but I included this in the here
so that we could look at each phase in turn briefly.
So the defining phase refers to the identification
of a project that's based on the strategic objectives
of the organization
and the customer's requirements of the process.
A good project should address an issue that's important
to the mission of the organization
and focus on a measurable improvement goal should be clearly
defined and easily measurable.
Speaking of measurement, the next phase measurement
describes the selection or development of a system
to accurately measure
how well the target process meets the requirements set.
Sometimes this measurement system may already exist
or it may be an innovation of the organization.
Next, the analysis phase refers
to the project team analyzing the data collected
using the measurement tool and providing information
to the development of quality improvement interventions.
Did this intervention work? Did it not work?
Do we need further innovations?
These are all questions that are answered
by the analysis phase.
Next, the improvement phase refers to the designing,
implementation and evaluation of the impact
of improvement interventions.
Possible interventions here can be identified
by reviewing the related literature.
And here oftentimes it's important
to have your intervention be based on the evidence
and find intervention that's been piloted,
that's been tested before,
and this is often referred
to an evidence-based intervention.
And finally, the last phase control refers
to the team working to institutionalize
successful process changes to sustain improvement gains.
Here this step facilitates the sustainability
of a certain improvement
and also plays a role in the fidelity
or how well that improvement is applied continuously over
time by different groups of people
and after the people who initially implemented
the intervention have left the organization.
So now we'll turn from Six Sigma to Lean,
and this is a quality improvement approach
that evolved from the Toyota Production System,
which was developed by Toyota's Chief of Production
in the years following World War II.
It uses an ongoing cycle of improvement to map out
and adapt process steps
that generate values from the customer's perspective
and to eliminate waste and unnecessary steps.
Again, when we think about this cycle,
we think about iteration.
The adoption of this methodology in healthcare is driven
by the pressure placed on health services organizations
to improve efficiency, reduce costs,
and streamline the care delivery process.
This methodology has five main principles,
value, the value stream, flow,
pull and perfection.
And while we've already talked about value in the value
system, flow and pull might be unfamiliar terms
and flow refers to the movement of products
or services through the value stream
without waste or delays.
While pull refers to the principle that requires
that the production process be triggered only
by customer demand.
Pull you might be familiar with when we,
during the COVID-19 pandemic and the ongoing pandemic,
there were supply chain shortages
and supply chain disruptions.
And related to pull is the idea
of just-on-time manufacturing when the production process is
triggered only when there's sufficient demand.
So now we turn to this chart,
which does a good job comparing Six Sigma and Lean,
and here we see that Six Sigma and Lean
have distinctive philosophies, tools, and techniques,
but they share a number of similar goals and approaches.
Increasingly though,
the two systems are being implemented concurrently
as Lean Six Sigma or LSS.
By integrating the two approaches,
this approach benefits both from the statistical rigor
of Six Sigma and from the cyclical waste reduction of Lean.
Six Sigma, Lean and the combination of the two have been
applied to projects to reduce costs, wait time, cycle time,
and adverse offense, as well as to increase patient volume,
patient safety, and patient satisfaction.
This figure depicts the level of operational change
and the use of quality improvement models.
It also shows the relationships and parallels
among the various models that are in use.
Advancements and methodologies in such areas as process
or service design are providing platforms with which
to explore disruptive innovations, especially when combined
with other methods.
In pursuing value-based healthcare, improvement models
consider two aspects of value,
the value perceived by internal and external clients,
and the organizational means that add value
in the chain of activities.
As process improvement advances in global health settings,
it emphasizes reconciliation, collaboration,
and engagement across all actors involved in a process,
which is all an important part
of the quality improvement philosophy.
Finally, we turn to looking at
the value added quality improvement
categories in global health.
So here we discussed the, or we're looking at
the four predominant value added categories,
the value added by novel process improvement
or innovation, the value added
by incremental process improvement, the value added
by decreasing process variation
and the value added by reducing waste, rework,
and costs in processes.
Caution needs to be exercised in assigning specific
categories to the various models, tools, and techniques.
Because the methods commonly overlap across multiple
categories and are often mixed.
The success of any of these interventions in healthcare
require capable management and organizational commitment
to quality and the embrace
of quality improvement principles and skills
as part of the organization's culture.
Process improvements may encounter cultural barriers
and resistance, and leaders will need
to influence people's mindsets, encourage openness,
and generate support for trying new ways.