Continuous Improvements in Hospital Settings

Six Sigma – iSixSigma Forums Industries Healthcare Continuous Improvements in Hospital Settings

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    Vasant Pawar

    Good morning.
    I am holding a very senior position in a group of institutions in which thee is a Medical School and a 650 bed hospital.
    The medical health care delivery process is highly fragmented because of involvement of many agencies / individuals in providing healthcare to an individual. This fragmentation brings in lot of variation in the process of delivery. Bringing in standardisation and efficiency is a big challenge.
    I think this is a universal challenge and is applicable to all healthcare institutions across the glob at various degree of severity.
    I want to open a discussion forum to address this issue at a global level.
    Please respond.



    Katie Barry

    @drvasant Did you search our site before posting? We have a whole section of healthcare content. Industries > Healthcare >




    You have a supply chain that needs to work together to produce a product/service for a customer. All parts of the chain need to work for it to work.

    However, each of the parts of the chain operate in their own environment, with their own management structure, processes, and priorities.

    So what you need to do, as a champion of the customer — who may die if they don’t get the right service — is get all the suppliers to agree that working together is of critical importance.

    You need to define every process, what are the inputs, what are the outputs, who is responsible, the key process metrics that you will all monitor, and every defect that is occurring.

    Once you have that information, it will become clear what needs to be done and by whom to improve outcomes.

    Do you agree?

    Where are you having difficulty?


    Vasant Pawar

    Ms katie & Mr Vinod,
    Good morning.
    1. Thank you for your inputs.
    2. Healthcare falls mainly in “services” domain and applying six sigma principles, which are mainly applicable for “manufacturing” domain, is a big challenge.
    3. The shear number of “Cure” and “Care” providers, and many people in between, brings in so much of variability in any activity / process that it becomes difficult to bring in any “standardization”. How to address “variability” issue to bring in standardization???


    Katie Barry


    In response to your question #3: Did you look at the section of content I directed you to? A quick search shows that a number of the articles address variation in healthcare. Did you read those articles for ideas/inspiration? (We also have a section of content about variation itself: Tools & Templates > Variation >

    What do YOU think the answer is/answers are? What are your ideas why/why not? The iSixSigma audience is extremely helpful, but they want to see someone is putting forth a good-faith effort. They are not here to do your thinking/work for you.


    Robert Butler

    I’m not trying to be mean spirited or offensive but your first major problem is your view as expressed in your second point.

    “2. Healthcare falls mainly in “services” domain and applying six sigma principles, which are mainly applicable for “manufacturing” domain, is a big challenge.”

    This just is not true. A hospital is nothing more than a repair and maintenance facility. The doctors are body mechanics, the nurses are technicians, and everyone else is there to support the throughput of repaired items. As a result, the issues faced by a hospital are no different than the issues faced by a jet aircraft repair and maintenance facility.

    From the standpoint of unit repair the doctors actually have it simultaneously easier and harder than an aircraft mechanic. They have it easier because they are dealing with a single model with components located in exactly the same place in every model. The reason they have it harder is because while they only have one model that model is an evolved model whereas the jet mechanic’s models, while exhibiting a wide variety with respect to components and component location are designed. The hallmark of evolution is complexity and the hallmark of design is simplicity.


    Mike Carnell

    @rbutler That is a great analogy and post post. You have credentials to back it up and it is true in my opinion.

    Just to follow on your anaolgy. The first thing you hear from Healthcare (actually sickcare) is that is if we screw up a person can die. If I am a jet engine mechanic on a 777 engine and screw up there are 550 lives at risk all in one shot. 757 = 283; 747 400 = 660; probably the most common is the 737 which can go up around 189. The airbus a380 can hold 853 passengers. Those are people who have other peoples lives in their hands!

    Thanks for jumping in this one.


    Chris Seider

    Health care will soon have the economic pressures on them that manufacturing has been under for over 30 years since Tricky Dick opened up China to the world.

    Of course, the US politicians can’t take good things from elsewhere and apply them in our borders. I still remember the awesomeness of being “able” to get prescription stuff for obvious afflictions while I spent time in South Africa. If I walked up with pink eye, I didn’t need a doctor’s prescription to get the appropriate medicine. No I didn’t have pink eye LOL but it’s an example.


    Vasant Pawar

    1. Health(sick)care cannot be compared with the repair / maintenance of an aircraft. The maintenance / repair process of a Boeing is a COMPLEX process requiring highly trained aeronautic engineers who, in coordination with each other, make the aircraft air-worthy. Moreover, it is a static process. The repair can wait till a consensus is arrived about when and how to proceed.
    2. In health(sick)care the situation invariably is very dynamic, and many a times it is COMPLICATED. A sick person can deteriorate rapidly and is gone before anybody realises what went wrong.
    3. In the “cure” and “care” team (including managers/administrators) there is involvement of many people with different educational backgrounds making the process even more COMPLICATED.
    4. In such a scenario, how can we simplify the learning from SIX SIGMA and apply them to health(sick)care?


    Robert Butler

    1. Regardless of how you choose to parse the need for repair – it is still a matter of repair and all of the issues/concerns that apply to one form of maintenance/repair facility apply to the rest.

    2. Complex and Complicated are synonyms therefore there is no distinction between the two.

    3. You triage aircraft repair and maintenance the same way you triage patient care. Aircraft maintenance and repair is very dynamic and the idea that every plane can just sit around somewhere burning money until a group of people decides what is best is incorrect.

    4. In aircraft maintenance and repair there are the equivalent of cure and care teams and they too have people from diverse educational backgrounds. The cure teams (note the “s” on the end of the last word) are involved in the cure – that is the actual act of repair. The care teams are involved with all of the issues surrounding the plane before it goes back into service and when it is in service.

    I’m not interested in turning this into a flame war or a he-said-she-said exchange but I think the bigger issue here is that your understanding of continuous improvement needs refinement. Since I have worked in the health field for a number of years and I apply six sigma methods on an almost daily basis let me provide you with a specific example of how it is done.

    Some years back we had a home care medication program that, in theory, should have been very good but was plagued by a number of problems with respect to getting the program underway and in use by the patient at home.

    I first met with a representative group of supervisors and managers to get an overview of the process. I used what they told me to build a flow chart of the process. This allowed me to tentatively identify the major parts of the process. I say “tentatively” because, regardless of how good a supervisor or a manager is they, by virtue of what they should be doing namely running interference for their employees, are not privy to all of the critical details of the process.

    Next I went to the floor and met with groups of nurses/technicians/suppliers associated with each of the main components of the flow chart. With each group I built a fishbone diagram of their part of the process. The fishbone not only diagrammed their specific part of the process it also included what they needed from prior steps in the process and what they expected to deliver to the next step of the process. From this I learned the following:

    1. There were critical major parts of the process which had not been listed by the manager/admin group.
    2. There was a lot of re-work going on – a total of three hidden factories in the process.
    3. The flow of needed information through the process as described by the manager/admin group had missed several critical elements and was in error with respect to other information elements.

    In each case, when we finished building the fishbone diagram of a particular piece of the process everyone present said they had no idea that their part of the effort was that complicated/complex.

    I took all of the diagrams, got a very large conference room, taped each of the fishbone diagrams in order of process flow on the wall and called a large meeting that included people from all levels of the process. Once everyone got over the surprise of actually seeing what the process really looked like we got down to specifics with respect to where and what kinds of measurements we needed to take in order to quantify what was going on.

    We agreed on a sampling plan for a number of different areas. I pointed out to everyone that I realized gathering this data would be an added burden to their respective work schedules so I also told them we were going to have a specific start and end date for all of the measurements and the start and end dates would be the same for everyone. We discussed the trade off for the need for representative data vs. the time involved and agreed that a month worth of data should be sufficient.

    Once all of the data was compiled I ran an analysis. For this particular project the statistical analysis was largely graphical (and yes, an appropriate graphical analysis is a statistical analysis) along with a few very basic statistical summaries.

    What we found was that well over 90% of the problems were due to two of the group of physicians involved in the evaluation process which determined who should and should not be permitted to have the home medication treatment. The analysis also showed it wasn’t their fault rather it was the fault of the system.

    The workload of the two physicians in question was much higher than the others in the evaluation group (I checked this just in case someone somewhere would try to claim they weren’t pulling their share of the load) and the added burden of correctly filling out all of the details in the paperwork that need to be provided was a simple case of work overload. The solution was simple – an assistant was assigned to them to take care of the paperwork as needed. The problem disappeared and various aspects of the existing process such as the hidden factories closed shop.



    There are four fundamental business models namely
    – manufacturing
    – service
    – asset plus service (healthcare, telecom, hospitality,)
    – trading

    Now all these models have core pillars basis which strategy shall revolve. For healthcare the pillars of asset plus service would apply, namely

    – asset deployment, utilisation and maintenance
    – productisation of service
    – supply chain to support productisation of service

    Fundamentally these becomes core end to end business processes. Each business processes need to have a measure (right and comprehensive one), which needs to be improved.

    Lean will focus on identifying customer perspective to the end to end business process and identifying what activities don’t add value and to remove them, making processes scalable and efficient. (for example: take process of patient coming in till patient leaves post recovery, giving you business in this whole process). We believe that there would be several requirements patient may have. Fundamentally there are only three (Value, Time, and Quality). The priority may vary across the end to end process which patient goes through till he moves out of the hospital.
    Now linking these requirements and collecting data to reduce variations to offer consistent service delivery, which establishes trusts, can be done using Six Sigma rigour.

    Essentially what i am trying to make you understand is that any continuous improvement methodology be it Lean or Six Sigma or any other, can be applied on any business process.

    The philosophy of any continuous improvement methodology is extremely powerful. The tools are techniques not just bring a structure to the way you look at things, it also imbibes internal locus of control (essential change management to improve things). Be it Lean or Six Sigma, they are focused to improve a business process purely to ensure customer/s needs are met (internal and external customer needs).

    Hope this helps !!

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