Posts Tagged ‘process improvement methodology’

Quality Guru Chosen to Head CMS

Tuesday, May 11th, 2010


Donald Berwick


Donald Berwick, a Harvard University professor and leading advocate for improving health-care quality and efficiency, has been named by President Obama as his choice to head the Centers for Medicare and Medicaid Services (CMS.) Berwick is well-known in Quality circles for aggressively advocating quality improvement in healthcare. Berwick, who specializes in health-care policy and pediatrics, has never led such a large organization. As head of the Boston-based Institute for Healthcare Improvement, however, he is known for persuading doctors and hospitals to adopt innovative methods for reducing medical errors. Dr. Berwick is author of numerous articles and books, including the classic work demonstrating the application of quality technology to health care issues, Curing Health Care. He is one of the nation’s leading authorities on health care quality and improvement. He is also Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, and Professor in the Department of Health Policy and Management at the Harvard School of Public Health.

If confirmed by the Senate, Berwick will face a number of daunting challenges. One is the sheer size of the CMS, which is about to become even larger. The agency, which is part of the Department of Health and Human Services, must oversee a massive expansion of Medicaid, the federal-state insurance program for the poor, with an estimated 16 million people expected to join its rolls by 2020. At the same time, Medicare, the insurance program for the elderly, will need to reduce payments to health-care providers by about $400 billion over 10 years without impacting the quality of coverage. Lean Six Sigma and Quality technologies provide an approach for doing this while minimizing the impact on value-added health care processes, operations and activities. Berwick’s familiarity with these areas provides reason for optimism or, at least, hope. This blog has frequently posted examples of poor quality in health care. Let’s hope that Dr. Berwick will have a positive impact at CMS.

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Six Sigma-Love It or Hate It?

Monday, June 15th, 2009

For a technical topic, Six Sigma tends to generate a lot of strong feelings. As the author of The Six Sigma Handbook I obviously have a few of these feelings myself. Still, on balance, I’m a Six Sigma “lover.” I think that the approach is an excellent way to help organizations achieve their goals by improving their core processes. However, I am not blind to the fact that Six Sigma also has its dark side. Here are a few examples that leap readily to mind.

Six Sigma everywhere. Some organizations apply Six Sigma where it really shouldn’t be applied. For example, one of my clients tried to apply it to an R&D operation. The poor folks trying to create something brand new from scratch were forced to try and figure out how to measure their progress, submit regular reports, track metrics on control charts, show process improvements, etc. It was a disaster. Six Sigma is a process improvement methodology, and it generally does this by reducing variation and eliminating errors and waste. Creativity involves innovation and risk taking. It deliberately introduces variability by changing things to try and discover something new. It is inherently and unavoidably wasteful. There is no process for understanding inspired creativity and it can’t be quantified until after it has generated failures and successes. The value of innovation can’t be measured until after something great has been achieved, and it’s not possible to tell if you’re 1% of the way to the achievement, or 99%. You won’t know until you get there.

The Elites Six Sigma has an infrastructure of “Belts” that have an air of elitism about them. Of course, there is also an air of elitism around other groups within an organization. In manufacturing it is the engineers, in healthcare the physicians, in insurance the actuaries. Why all of the animosity towards the Belts? My theory is that it happens so fast, and it happens to people who already have a defined status in the organization. One minute John or Jane are ordinary blokes, the next they are exalted Black Belts. What’s up with that? To help promote Six Sigma in organizations just starting the initiative, the newly minted Belts are announced on the company web site and written about in the company newspaper. To make matters worse, the group of Belts use jargon that others can’t understand and, frankly, some of them lord their new status over others.

Still, having this cadre of people whose job it is to pursue change project is perhaps the single most important thing that made Six Sigma work where TQM and other change initiatives failed. Organizations didn’t just mouth nice sounding words about the importance of change, they put their resources where their mouths were.

Most people don’t like change. In my boyhood home of Nebraska there was a common saying, “If it ain’t broke, don’t fix it.” The message was clear: don’t change anything unless it is absolutely necessary. The problem with this approach is that, in a world where your competitors are changing things at a rapid rate, if you wait until the need for change is painfully obvious, you may be too late.

Nobody wants someone telling them how to do their work. If you’ve been doing a job for a while, chances are you’ve become pretty good at it. No matter how much training you received, you learned a lot from the school of hard knocks. Now along comes this bunch of outsiders telling you that they have a better way of doing things. The reaction? Yeah, Right! If the team knows what they’re doing they will ask you for your input and they will use it to make your job easier or better. But if they don’t, they’ll make it harder and less pleasant.

Fear of job loss. It can be frightening to see how much waste there actually is in some systems. I’ve seen departments with 25 people before a Six Sigma project and 5 afterwards. The smart company will plan for this kind of impact and have new jobs for those no longer needed. But many companies simply let the displaced people go. It’s no wonder that the result is fear of Six Sigma shining a light into your work area.

Unintended consequences. If the team isn’t extremely careful, Six Sigma projects can break one thing as they improve another. The control phase of the project is supposed to prevent this from occurring, but sometimes it happens anyway. Despite all efforts there will be times when changing something results in unforeseen problems, it is the nature of change. When it happens, it will produce resentment.

Six Sigma is used when a simpler approach would’ve worked just as well. Six Sigma DMAIC or DfSS projects have their rightful place. But let’s face it, the Six Sigma approach is a problem-solving sledge hammer. Sometimes a fly swatter is more appropriate.

Six Sigma people get credit for ideas originally conceived by others. One of the main bailiwicks of Six Sigma is the problem that has been “solved” over and over again. When chronic problems are attacked by Six Sigma teams it is almost certain that the final solution will incorporate elements of things that were proposed, and maybe even tried, in the past. The people who had thought of the the fix before the Six Sigma team probably tried and failed to get their solutions implemented. Six Sigma tends to receive more resources and management support than lone problem solvers. The resulting hurt feelings can be ameliorated-but not eliminated-by recognizing those who tried to raise the flag in the past.

While some of these things can be avoided, Six Sigma will always have its dark side. Six Sigma is all about change and change is inherently risky. However, change is also vital to survival. The battle between stagnation and chaos is never ending.

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Why Isn’t Six Sigma Used More in Healthcare?

Thursday, April 9th, 2009

Apparently there are still questions about whether or not a process improvement methodology like lean or Six Sigma can work in healthcare. I find this astonishing and disingenuous. The only real requirement for deploying any process improvement is whether or not there is a process that is done more than once. Healthcare at any respectably sized organization involves thousands of patients, procedures, images, admissions, discharges, transfers, prescriptions, physician orders, medication administration, IV line insertions, laboratory tests. Need I go on?

Every time one of these things take place there are many ways they can go wrong. Patients can be misdiagnosed, emergencies can take too long to attend do, images can be poorly done or misinterpreted, admissions can be too time consuming and expensive, discharges can take place too early or without adequate instruction, transfers can injure patients, prescriptions can be issued in error or filled in error, physician’s orders can be incorrect or incorrectly interpreted or incorrectly followed, medications can be incorrectly administered, IV lines can become infected, lab tests can be done incorrectly or cost too much or take too long to do.

So, we have a very long list of clinical and non-clinical healthcare processes. For every process we have a very long list of things that can go wrong with the process, and an equally long list of ways in which the process can be done better.

Over 20 years ago the National Demonstration Project on Quality Improvement in Healthcare examined the applicability of quality methods to healthcare issues. They concluded

What is truly unique about the field of quality control is not its tools, but its ethos–the set of attitudes that it brings to quality problems.

Here’s a short list of what is included in this ethos

  • Prevention is preferable to detection.
  • Focus on the system, not the individual
  • The customer is central
  • Variation is endemic. Different types of variation require different types of responses
  • Quality should be defined broadly. It is not simply quality of care that matters, but also quality of service, amenities, reliabilitiy–all of the aspects of the healthcare encounter.

The NDP proved that the quality approach (aka Six Sigma and Lean) had value to the healthcare community, but there has never been widespread acceptance. I believe that the root cause of this is a system of perverse economic incentives that makes poor quality pay. A c-section poses higher risk to the mother and the baby. But whether or not a c-section is needed is a judgment call. If one is performed it costs several thousand additional dollars. Those dollars are revenue to the hospital and income to a physician, an anesthesiologist and other professionals and care providers. These are simple facts that can’t help but influence the decision-making process. When Six Sigma or Lean come along and promise to drastically reduce problems and system failures, it is only natural that the people involved consider the impact on their top and bottom lines. Until this situation changes, process excellence will be a tough sell in healthcare.

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Resources for Six Sigma


Introduction to Six Sigma
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Good books on Six Sigma and other topics

What is Six Sigma?

By Thomas Pyzdek, Author of The Six Sigma Handbook

For Motorola, the originator of Six Sigma, the answer to the question "Why Six Sigma?" was simple: survival. Motorola came to Six Sigma because it was being consistently beaten in the competitive marketplace by foreign firms that were able to produce higher quality products at a lower cost. When a Japanese firm took over a Motorola factory that manufactured Quasar television sets in the United States in the 1970s, they promptly set about making drastic changes in the way the factory operated. Under Japanese management, the factory was soon producing TV sets with 1/20th the number of defects they had produced under Motorola management. They did this using the same workforce, technology, and designs, making it clear that the problem was Motorola's management. Eventually, even Motorola's own executives had to admit "our quality stinks." Read More...