WEBVTT 1 00:00:00.720 --> 00:00:02.250 Hi everyone. 2 00:00:02.250 --> 00:00:04.620 In this lecture, we're going to be continuing discussing 3 00:00:04.620 --> 00:00:06.150 process design and continuous 4 00:00:06.150 --> 00:00:08.160 quality improvement in healthcare. 5 00:00:08.160 --> 00:00:12.840 So to continue, we mentioned Six Sigma and Lean 6 00:00:12.840 --> 00:00:17.160 in the last lecture, and they are two tools 7 00:00:17.160 --> 00:00:21.930 or methodologies that are often used in quality improvement. 8 00:00:21.930 --> 00:00:24.303 They're helpful in improving patient outcomes. 9 00:00:25.350 --> 00:00:27.840 The application of these methodologies in the healthcare 10 00:00:27.840 --> 00:00:30.690 industry is driven in large part by the successes 11 00:00:30.690 --> 00:00:34.530 of these two methodologies in the manufacturing industry. 12 00:00:34.530 --> 00:00:37.650 As you've seen oftentimes throughout this lecture, 13 00:00:37.650 --> 00:00:42.120 a lot of the tools and practices used in healthcare 14 00:00:42.120 --> 00:00:44.790 quality improvement were initially developed 15 00:00:44.790 --> 00:00:48.150 in manufacturing, and it bear many similarities 16 00:00:48.150 --> 00:00:51.873 to any production or industrial process. 17 00:00:53.730 --> 00:00:57.510 This is also, these have also been taken up 18 00:00:57.510 --> 00:00:58.890 and used more often, 19 00:00:58.890 --> 00:01:01.230 because there's been a greater emphasis on quality 20 00:01:01.230 --> 00:01:04.140 of care in healthcare than there has been in the past. 21 00:01:04.140 --> 00:01:06.420 For example, in the United States, 22 00:01:06.420 --> 00:01:09.030 hospitals can receive additional payments from the sector 23 00:01:09.030 --> 00:01:12.284 for Medicare and Medicaid services or the CMS, 24 00:01:12.284 --> 00:01:14.400 if they improve patient satisfaction 25 00:01:14.400 --> 00:01:16.530 and lower readmission rates among patients 26 00:01:16.530 --> 00:01:18.780 with certain medical conditions. 27 00:01:18.780 --> 00:01:21.822 Therefore, healthcare organizations are very motivated 28 00:01:21.822 --> 00:01:24.033 to improve patient outcomes. 29 00:01:24.972 --> 00:01:29.972 So to begin with, Six Sigma is a quality improvement 30 00:01:31.320 --> 00:01:33.750 methodology that was developed at the Motorola Corporation 31 00:01:33.750 --> 00:01:37.200 in the 1980s that emphasizes the elimination 32 00:01:37.200 --> 00:01:38.940 of variation in error. 33 00:01:38.940 --> 00:01:40.410 How does it work? 34 00:01:40.410 --> 00:01:43.050 So it uses Sigma levels to reflect the total number 35 00:01:43.050 --> 00:01:45.570 of defects per million opportunities. 36 00:01:45.570 --> 00:01:49.110 The higher the Sigma level, the lower the number of defects. 37 00:01:49.110 --> 00:01:51.720 The goal of Six Sigma is to reduce the rate of defects 38 00:01:51.720 --> 00:01:53.080 to a Six Sigma level 39 00:01:54.090 --> 00:01:57.213 or 3.4 defects per million opportunities. 40 00:01:58.590 --> 00:02:00.840 As we know, if you've studied statistics before, 41 00:02:00.840 --> 00:02:03.210 Sigma is a symbol for standard deviation, 42 00:02:03.210 --> 00:02:05.100 and the name Six Sigma reflects the goal 43 00:02:05.100 --> 00:02:07.500 of having process outputs within a span 44 00:02:07.500 --> 00:02:11.250 of six standard deviations, or the mean plus or minus 45 00:02:11.250 --> 00:02:12.813 three standard deviations. 46 00:02:14.670 --> 00:02:17.040 Six Sigma projects in healthcare settings can help reduce 47 00:02:17.040 --> 00:02:19.980 waiting times and delays, prevent adverse effects, 48 00:02:19.980 --> 00:02:22.680 lower costs, and improve other patient outcomes. 49 00:02:22.680 --> 00:02:23.853 Not noted here. 50 00:02:24.930 --> 00:02:26.340 This reflects not only an approach 51 00:02:26.340 --> 00:02:28.320 for quality improvement, 52 00:02:28.320 --> 00:02:32.613 but also a key part of quality improvement philosophy. 53 00:02:34.440 --> 00:02:38.880 The cornerstone of Six Sigma is process management 54 00:02:38.880 --> 00:02:41.940 through the DMAIC cycle, 55 00:02:41.940 --> 00:02:43.950 and DMAIC is called that 56 00:02:43.950 --> 00:02:46.050 because it stands for five phases. 57 00:02:46.050 --> 00:02:49.170 Define, measure, analyze, 58 00:02:49.170 --> 00:02:51.243 improve, and control. 59 00:02:52.170 --> 00:02:56.490 And again, this chapter loves these lengthy 60 00:02:56.490 --> 00:02:58.080 and wordy charts, 61 00:02:58.080 --> 00:03:00.390 but I included this in the here 62 00:03:00.390 --> 00:03:04.560 so that we could look at each phase in turn briefly. 63 00:03:04.560 --> 00:03:09.300 So the defining phase refers to the identification 64 00:03:09.300 --> 00:03:11.640 of a project that's based on the strategic objectives 65 00:03:11.640 --> 00:03:13.020 of the organization 66 00:03:13.020 --> 00:03:15.423 and the customer's requirements of the process. 67 00:03:16.710 --> 00:03:19.005 A good project should address an issue that's important 68 00:03:19.005 --> 00:03:20.790 to the mission of the organization 69 00:03:20.790 --> 00:03:23.820 and focus on a measurable improvement goal should be clearly 70 00:03:23.820 --> 00:03:25.623 defined and easily measurable. 71 00:03:27.140 --> 00:03:30.686 Speaking of measurement, the next phase measurement 72 00:03:30.686 --> 00:03:35.686 describes the selection or development of a system 73 00:03:36.210 --> 00:03:37.080 to accurately measure 74 00:03:37.080 --> 00:03:40.350 how well the target process meets the requirements set. 75 00:03:40.350 --> 00:03:43.470 Sometimes this measurement system may already exist 76 00:03:43.470 --> 00:03:46.383 or it may be an innovation of the organization. 77 00:03:48.480 --> 00:03:50.880 Next, the analysis phase refers 78 00:03:50.880 --> 00:03:53.070 to the project team analyzing the data collected 79 00:03:53.070 --> 00:03:55.372 using the measurement tool and providing information 80 00:03:55.372 --> 00:03:58.380 to the development of quality improvement interventions. 81 00:03:58.380 --> 00:04:01.140 Did this intervention work? Did it not work? 82 00:04:01.140 --> 00:04:02.520 Do we need further innovations? 83 00:04:02.520 --> 00:04:03.900 These are all questions that are answered 84 00:04:03.900 --> 00:04:05.133 by the analysis phase. 85 00:04:06.270 --> 00:04:10.410 Next, the improvement phase refers to the designing, 86 00:04:10.410 --> 00:04:13.900 implementation and evaluation of the impact 87 00:04:15.330 --> 00:04:17.313 of improvement interventions. 88 00:04:18.510 --> 00:04:21.180 Possible interventions here can be identified 89 00:04:21.180 --> 00:04:23.430 by reviewing the related literature. 90 00:04:23.430 --> 00:04:25.130 And here oftentimes it's important 91 00:04:26.010 --> 00:04:29.520 to have your intervention be based on the evidence 92 00:04:29.520 --> 00:04:32.520 and find intervention that's been piloted, 93 00:04:32.520 --> 00:04:34.830 that's been tested before, 94 00:04:34.830 --> 00:04:35.940 and this is often referred 95 00:04:35.940 --> 00:04:38.370 to an evidence-based intervention. 96 00:04:38.370 --> 00:04:41.911 And finally, the last phase control refers 97 00:04:41.911 --> 00:04:44.520 to the team working to institutionalize 98 00:04:44.520 --> 00:04:48.090 successful process changes to sustain improvement gains. 99 00:04:48.090 --> 00:04:51.990 Here this step facilitates the sustainability 100 00:04:51.990 --> 00:04:53.380 of a certain improvement 101 00:04:54.240 --> 00:04:56.717 and also plays a role in the fidelity 102 00:04:56.717 --> 00:05:00.870 or how well that improvement is applied continuously over 103 00:05:00.870 --> 00:05:03.120 time by different groups of people 104 00:05:03.120 --> 00:05:05.820 and after the people who initially implemented 105 00:05:05.820 --> 00:05:08.020 the intervention have left the organization. 106 00:05:09.360 --> 00:05:12.240 So now we'll turn from Six Sigma to Lean, 107 00:05:12.240 --> 00:05:14.760 and this is a quality improvement approach 108 00:05:14.760 --> 00:05:17.760 that evolved from the Toyota Production System, 109 00:05:17.760 --> 00:05:19.800 which was developed by Toyota's Chief of Production 110 00:05:19.800 --> 00:05:21.990 in the years following World War II. 111 00:05:21.990 --> 00:05:24.660 It uses an ongoing cycle of improvement to map out 112 00:05:24.660 --> 00:05:25.890 and adapt process steps 113 00:05:25.890 --> 00:05:28.680 that generate values from the customer's perspective 114 00:05:28.680 --> 00:05:32.010 and to eliminate waste and unnecessary steps. 115 00:05:32.010 --> 00:05:33.450 Again, when we think about this cycle, 116 00:05:33.450 --> 00:05:35.640 we think about iteration. 117 00:05:35.640 --> 00:05:38.730 The adoption of this methodology in healthcare is driven 118 00:05:38.730 --> 00:05:40.860 by the pressure placed on health services organizations 119 00:05:40.860 --> 00:05:43.230 to improve efficiency, reduce costs, 120 00:05:43.230 --> 00:05:45.393 and streamline the care delivery process. 121 00:05:46.290 --> 00:05:49.980 This methodology has five main principles, 122 00:05:49.980 --> 00:05:53.610 value, the value stream, flow, 123 00:05:53.610 --> 00:05:55.533 pull and perfection. 124 00:05:56.400 --> 00:05:58.740 And while we've already talked about value in the value 125 00:05:58.740 --> 00:06:02.070 system, flow and pull might be unfamiliar terms 126 00:06:02.070 --> 00:06:04.530 and flow refers to the movement of products 127 00:06:04.530 --> 00:06:06.000 or services through the value stream 128 00:06:06.000 --> 00:06:07.680 without waste or delays. 129 00:06:07.680 --> 00:06:11.520 While pull refers to the principle that requires 130 00:06:11.520 --> 00:06:13.320 that the production process be triggered only 131 00:06:13.320 --> 00:06:14.643 by customer demand. 132 00:06:16.110 --> 00:06:21.110 Pull you might be familiar with when we, 133 00:06:21.690 --> 00:06:24.753 during the COVID-19 pandemic and the ongoing pandemic, 134 00:06:25.620 --> 00:06:27.270 there were supply chain shortages 135 00:06:27.270 --> 00:06:28.800 and supply chain disruptions. 136 00:06:28.800 --> 00:06:31.050 And related to pull is the idea 137 00:06:31.050 --> 00:06:35.400 of just-on-time manufacturing when the production process is 138 00:06:35.400 --> 00:06:38.523 triggered only when there's sufficient demand. 139 00:06:41.970 --> 00:06:43.890 So now we turn to this chart, 140 00:06:43.890 --> 00:06:46.923 which does a good job comparing Six Sigma and Lean, 141 00:06:47.850 --> 00:06:50.490 and here we see that Six Sigma and Lean 142 00:06:50.490 --> 00:06:53.100 have distinctive philosophies, tools, and techniques, 143 00:06:53.100 --> 00:06:56.280 but they share a number of similar goals and approaches. 144 00:06:56.280 --> 00:06:57.990 Increasingly though, 145 00:06:57.990 --> 00:07:00.480 the two systems are being implemented concurrently 146 00:07:00.480 --> 00:07:03.420 as Lean Six Sigma or LSS. 147 00:07:03.420 --> 00:07:05.460 By integrating the two approaches, 148 00:07:05.460 --> 00:07:08.520 this approach benefits both from the statistical rigor 149 00:07:08.520 --> 00:07:12.483 of Six Sigma and from the cyclical waste reduction of Lean. 150 00:07:13.860 --> 00:07:16.830 Six Sigma, Lean and the combination of the two have been 151 00:07:16.830 --> 00:07:20.100 applied to projects to reduce costs, wait time, cycle time, 152 00:07:20.100 --> 00:07:23.640 and adverse offense, as well as to increase patient volume, 153 00:07:23.640 --> 00:07:26.223 patient safety, and patient satisfaction. 154 00:07:28.680 --> 00:07:32.040 This figure depicts the level of operational change 155 00:07:32.040 --> 00:07:34.443 and the use of quality improvement models. 156 00:07:35.770 --> 00:07:38.820 It also shows the relationships and parallels 157 00:07:38.820 --> 00:07:42.120 among the various models that are in use. 158 00:07:42.120 --> 00:07:44.853 Advancements and methodologies in such areas as process 159 00:07:44.853 --> 00:07:47.700 or service design are providing platforms with which 160 00:07:47.700 --> 00:07:50.880 to explore disruptive innovations, especially when combined 161 00:07:50.880 --> 00:07:52.113 with other methods. 162 00:07:54.060 --> 00:07:58.140 In pursuing value-based healthcare, improvement models 163 00:07:58.140 --> 00:08:00.213 consider two aspects of value, 164 00:08:01.650 --> 00:08:04.920 the value perceived by internal and external clients, 165 00:08:04.920 --> 00:08:05.919 and the organizational means that add value 166 00:08:05.919 --> 00:08:09.213 in the chain of activities. 167 00:08:11.520 --> 00:08:14.700 As process improvement advances in global health settings, 168 00:08:14.700 --> 00:08:19.020 it emphasizes reconciliation, collaboration, 169 00:08:19.020 --> 00:08:22.290 and engagement across all actors involved in a process, 170 00:08:22.290 --> 00:08:24.210 which is all an important part 171 00:08:24.210 --> 00:08:29.210 of the quality improvement philosophy. 172 00:08:32.070 --> 00:08:34.600 Finally, we turn to looking at 173 00:08:35.670 --> 00:08:37.080 the value added quality improvement 174 00:08:37.080 --> 00:08:38.613 categories in global health. 175 00:08:40.410 --> 00:08:45.410 So here we discussed the, or we're looking at 176 00:08:48.742 --> 00:08:52.140 the four predominant value added categories, 177 00:08:52.140 --> 00:08:54.120 the value added by novel process improvement 178 00:08:54.120 --> 00:08:56.040 or innovation, the value added 179 00:08:56.040 --> 00:08:58.800 by incremental process improvement, the value added 180 00:08:58.800 --> 00:09:00.990 by decreasing process variation 181 00:09:00.990 --> 00:09:03.540 and the value added by reducing waste, rework, 182 00:09:03.540 --> 00:09:05.550 and costs in processes. 183 00:09:05.550 --> 00:09:07.920 Caution needs to be exercised in assigning specific 184 00:09:07.920 --> 00:09:10.680 categories to the various models, tools, and techniques. 185 00:09:10.680 --> 00:09:13.290 Because the methods commonly overlap across multiple 186 00:09:13.290 --> 00:09:15.543 categories and are often mixed. 187 00:09:16.800 --> 00:09:19.410 The success of any of these interventions in healthcare 188 00:09:19.410 --> 00:09:22.500 require capable management and organizational commitment 189 00:09:22.500 --> 00:09:24.780 to quality and the embrace 190 00:09:24.780 --> 00:09:27.690 of quality improvement principles and skills 191 00:09:27.690 --> 00:09:30.030 as part of the organization's culture. 192 00:09:30.030 --> 00:09:32.220 Process improvements may encounter cultural barriers 193 00:09:32.220 --> 00:09:33.600 and resistance, and leaders will need 194 00:09:33.600 --> 00:09:36.360 to influence people's mindsets, encourage openness, 195 00:09:36.360 --> 00:09:38.493 and generate support for trying new ways.