Blogging A Book: Sharing the Secret of Lean & Six Sigma In Healthcare (Introduction)





Editor/Author’s note:  Hello All.  As we described earlier on the blog, we’ll be releasing pieces of the e-book we’re writting:  Sharing The Secret of Lean & Six Sigma In Healthcare.  Here’s our rough copy introduction–feedback always welcome.





Introduction–Why Bother With The Hunt For Effective Quality Improvement?


By:  DM Kashmer, MD MBA FACS

Lean Six Sigma Master Black Belt (MBB)



Healthcare Is In A Bad Place


If you work in or around healthcare you know there are many challenges that we are facing as a group.  After all, we have heard the story of quality challenges in healthcare for the last decade or more.  We have heard the fact, over and over again, that the United States spends more than 14% of its Gross Domestic Product on healthcare each year.  For this amount of expenditure, our quality endpoints are poor at best according to many classic measures.  What has this translated into?  Many of us feel that we are currently in age of cost containment.  What I mean by this is there is a strong focus, now, on decreasing the cost of healthcare to the exclusion of much else.  Some assert that the cry of “quality!” really is being used as a stick to control costs.  You may or may not agree and of course that’s ok–and either way, reading on is worth your time.



Many Classic Quality Improvement Tools That Could Help Are Unknown Or Shunned


Unfortunately, many of the classic tools for quality improvement are either shunned or unknown in healthcare…and that’s why this book exists.  In this book, we explore many of the classic quality tools and describe how they can be deployed effectively in healthcare.  Why do we do this?  This book is written for one simple reason:  improving quality can decrease the amount of costs we endure for poor quality–and when I say “costs”, by the way, I don’t just mean financial costs.  After all, since most service industries operate at one defect in every one thousand opportunities at making a defect (yes I’m talking to you here healthcare) the issues associated with our current performance are many and go far beyond simple finance.  At the end of the day, the Cost of Poor Quality (COPQ) includes things like re-operation, wrong site surgery, and many other problems that go beyond financial considerations.


And remember healthcare friends:  just because you don’t know about Lean and Six Sigma (yet) doesn’t mean they don’t work.  In fact, they are very effective and (just like healthcare) they take some expertise and training.  You’ll be even more surprised to hear that much of both Lean and Six Sigma is really just utilizing tools that you’ve heard of such as histograms, multiple regressions, and other classic statistical implements you’ve learned about in healthcare training–it’s just that these are put together and arranged in certain ways to help a group own its process and implement positive change that is measurable and rigorous.


Quality Improvement Teaches Us Many Issues Aren’t Just People Issues


It’s clear that, if we are able to improve quality, waste in terms of financial waste and other waste is substantially reduced.  Currently, often, we hear the refrain of physician-work-harder or (“doc work harder”).  Don’t get me wrong–I’m no stranger to work and in fact I don’t mind it.  Work is what got me through medical school, residency, and to this point in my life.  However, “doc work harder” is not a valid solution for quality improvement.  It turns out, after all, that many quality issues that healthcare deems “personally assignable” are actually much more multi-factorial.  If we want a real way to improve quality that works, let’s try something different than the blame game we see too often in healthcare.  It divides us as physicians and practitioners.  So let’s listen to the data from the quality improvement world and actually use the tools.



Externally Imposed Endpoints Would Likely Be Satisfied With An Increased Internal Focus On Quality


Also, as a physician, I often feel that my time with patients and attention to detail is limited owing to system issues.  One of the reasons why is that in hospitals, the revenue side is most sensitive to patient volume.  That is, proformas in hospitals are most sensitive to patient volume.  See more patients, treat more patients, and go go go.  As a result, my ability to care for individual patients and spend time is limited.  It is easy to see the impact of volume on the hospital’s bottom line.  However, it’s not so easy to see the impact of the COPQ and this is part of why a quality focus is often brought to healthcare from without (eg the government and things like “never” events or SCIP measures) rather than from within.  If we followed the tools in this book and the philosophy of Lean and Six Sigma, SCIP measures and similar endpoints would be met or exceeded as a consequence.  More on that later.


I view quality improvement as one type of investment that allows me to spend more time with patients and treat more patients effectively and compassionately.



The Sibling of Quality Improvement Is Innovation


As I depart the soapbox and we turn toward the tools and tips, let me share that perhaps the brother or sister to quality improvement is innovation.  It’s one thing to refine a system with quality tools and yet it is quite another to build one with quality in mind in the first place.  That is, if we can innovate the business models with which we deliver care, we can perhaps break out of the “volume crunch” that we are currently experiencing in Healthcare and Surgery.



Better To Work In A System That Sets Us Up For Success


Disclaimer here before we go to the tools:  I love to work and operate.  I add that in because, in healthcare and surgical culture, a quality focus or mentioning quality is often taken as a synonym or code-word associated with someone who doesn’t like work.  Let me share with you all that, in fact, a high-quality, high-performing system enables more work to get done with less re-work.  That’s the aim here:  it would be better to be able to deliver higher quality care in a system that’s built to set us up for success.



Use The Tools–Don’t Reinvent The Wheel


Please enjoy this series of quality control tools, and their rationales, applied to healthcare.  Consider using them–don’t re-invent the wheel in the hunt for tools that already exist and work.  These are written up as vignettes with a focus on either a philosophy or tool of the process and its uses.  There is also a focus on innovation, with these tools offered to demonstrate how to take an innovative process and refine it.  After all, if we can innovate business models and evolve streams of revenue that are not sensitive to patient volume, well, we may be able to effectively deliver care and break out of the difficult cycle in which healthcare currently finds itself.  It would be great to be less focused on patient volume and more focused on quality care, innovative means of delivery, and new ideas to decrease the pressure to see more and more patients so we can be able to spend more time delivering higher quality care.


–David 5/16/14