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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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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.

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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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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:

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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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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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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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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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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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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?”

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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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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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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

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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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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,

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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).

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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

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Management, Project Management, Change Management, Manufacturing Management,

Strategic Management, General Management Principles, Systems Management, Statistics,

Customer Service, Engineering Economy, and Human Factors Engineering.