Vol. 15 •Issue 21 • Page 16
Process Improvement: Tools and Methodologies for the 21st Century
By Leslie Ann Fox, MA, RHIA, and Patty Thierry SHERIDAN, MBA, RHIA, CCS
Leslie: My interest is piqued. Health care organizations across the country are earning green belts, black belts, holding work out sessions and becoming students of process improvement methods.
Patty: It’s unlike the process improvement emphasis previously experienced in health care. There have been methodologies introduced over the past decade such as Six Sigma, Balanced Scorecard and Rapid Redesign, but older methodologies such as Workout Sessions, Plan Do Check Act (PDCA) Methodology and Total Quality Improvement (TQM) still have an important role in the process improvement tool kit. The methodology that most health care organizations are adopting is Six Sigma. This methodology was first invented by Motorola to correct poor manufacturing quality and later adopted by General Electric among other corporations.
Leslie: With the focus on reducing medical errors and increasing patient safety, it makes sense to me that the health care industry look to the lessons of the manufacturing industry for methods of improving processes and achieving very low error rates.
Patty: Six Sigma stands apart from other process improvement methods because it focuses on reducing variability thereby reducing errors or achieving defect free products or services. It’s seems like the perfect methodology to apply in reducing medical errors in our country.
Leslie: The use of Six Sigma in the manufacturing environment has resulted in significant improvements in quality from which we as consumers have benefited. As I understand it, the focus is on defect prevention as opposed to defect detection.
Patty: That’s right. Six Sigma is a philosophy and perspective about quality and a way of running a business. It is not a program and it is not solely about solving problems. Six Sigma uses a number of tools and processes such as DMAIC, which is define, measure, analyze, improve and control. This is a scientific process that is systematic and based on data. Six Sigma places a heavy emphasis on data to drive decisions. But it also considers business savvy in the equation. The General Six Sigma Electric Training Manual indicates data is important because of the following:
“We don’t know what we don’t know meaning our knowledge is always incomplete.”
“If we can’t express what we know in the form of numbers, we really don’t know much about it.”
“If we don’t know much about it, we can’t control it.”
“If we can’t control it, we are at the mercy of chance.”
Leslie: Those are good statements to help put the importance of data in context. Six Sigma is not the be-all and end-all for business improvement but I like that it is based on data where other improvement methods like re-engineering tend not to be so data focused. Oh, I was so involved in the conversation I forgot to ask, what are green belts and black belts?
Patty: They are levels of expertise in understanding of Six Sigma methods, the use of Six Sigma tools, and knowledge of statistical concepts. There are a number of formal training programs to learn Six Sigma and to earn one’s green or black belt. Books and online courses are also available.
Leslie: I like the classification. You mentioned some other process improvement methods earlier in our discussion. What are they?
Patty: There are a number of process improvement methods but what you learn quickly when you study the different methods, is that they often compliment each other. You might be involved in a Six Sigma process and will implement the PDCA cycle or hold a Workout Session. Workout Sessions are a structured problem-solving approach developed by GE.
Leslie: I remember the TQM methodology became really popular in the 1980s; I am most interested to understand when it is best to use this methodology.
Patty: TQM can be considered an evolutionary process improvement method in comparison to Six Sigma and Rapid Redesign. The latter methods both are considered revolutionary. For example, TQM or continuous quality improvement (CQI) are methods that are more incremental in nature. Thus the outcomes of these methods tend to fine tune existing processes or are more evolutionary. TQM goals for example might be used to reduce coding errors by 5 percent or reduce transcription turnaround time by an additional 8 hours without adding staff.
Leslie: TQM/CQI also tends to focus on one aspect of a process at a time, which might result in ignoring other parts of the system that are not included in the process that is being studied.
Patty: That’s true, and it’s a common criticism of TQM/CQI. But these methods are important in health care and continue to be a useful methodology for incrementally improving processes or studying a particular part of a process. TQM for example would not work well in crafting the vision of the electronic health record (EHR) and the processes that need to support it. Nor will it be fast enough.
Leslie: In a previous Hands-On Help column titled “The Future State of HIM: A Bold New Vision” (ADVANCE, Aug. 15, 2005) we talked about how challenging it is to develop HIM services in a nanosecond world.
Patty: Speed is an important strategy and the revolutionary process improvement methods are more likely to be successful than evolutionary methods when an organization is in the midst of a significant transformation, as health care organizations are now.
Leslie: You mentioned Rapid Redesign before as a process improvement methodology. What is the philosophy of this method?
Patty: Rapid Redesign brings together colleagues, who work within a process, to participate in redesign efforts. The outcomes of these efforts typically result in breakthrough improvements and/or the creation of new end products. As the name implies, this methodology is fast. It is a highly focused, facilitated process that occurs over a very short period of time.
Leslie: Sounds intense. Where did this process improvement method come from?
Patty: From the manufacturing industry. Boeing and Daimler Chrysler implemented Rapid Redesign in the early 90s as part of their quality initiatives. Through lessons learned, they came to believe that significant improvements were generally produced when they were created under short and focused timeframes.
Leslie: Interesting. Tell us more about the process.
Patty: In general, Rapid Redesign is usually kicked off by a week-long workshop. An infrastructure is created for the Rapid Resign process. It includes sponsors, process owners and the Rapid Redesign team. There are rules to be followed and required deliverables. By the end of the workshop, new processes, new departments, new products and/or services will have been created along with work plans. On the Monday morning following the workshop, 80 percent of the first steps for each work flow identified within the plan must be implemented.
Leslie: It sounds like an intense 5 days of designing and planning. It requires the attendees of the workshop to envision new ways of doing things and creating new functions, processes and structures. What kinds of tools are used to help create new processes?
Patty: The tools include: various brainstorming techniques, root cause analysis, mind mapping, gap analysis, force field analysis, simulation, “Five Whys,” Interrelationship diagramming and something called What-So What-Now What.
Leslie: What-So What-Now What?
Patty: It’s called a reflection exercise. Basically, it’s a facilitated discussion on these questions:
• What did we just accomplish?
• So what does it mean? Why did we do it?
• Now what do we do?
Leslie: Now that we are taking about this, I recall a client we worked with who implemented Rapid Redesign to develop their vision of e-HIM.
Patty: It’s a great process for reinventing and rethinking mental models. Also, modifications of Rapid Redesign are used in developing and customizing various clinical and administrative information systems.
Leslie: It seems to me that learning about process improvement methods provides HIM professionals with additional perspective and tools to navigate change and solve problems. Given the aggressive national patient safety goals adopted by JCAHO and other regulatory bodies, I suspect we are experiencing the beginning of a wide spread movement toward Six Sigma. Many experts predict it will become the foundation for performance improvement in health care. Time will tell if this process improvement method is here to stay and truly revolutionizes health care by reducing costs and variability. Stay tuned!
Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to [email protected] or [email protected].