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Applying production-line methods to PBC

29 October 2008 Using techniques normally employed in manufacturing in PBC may seem off the wall, but it can help eliminate waste and improve patient care, says Dr Paresh Dawda
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Using techniques normally employed in manufacturing in PBC may seem off the wall, but it can help eliminate waste and improve patient care, says Dr Paresh Dawda. Can you really apply car production line techniques to treating patients? There are many parallels between what we do as clinicians and the process of quality improvement in a manufacturing process. If a patient presents with a symptom we could see that as a failure of a biological process. As clinicians we try to diagnose the cause of that symptom using a number of tools such as taking a clinical history, clinical examination and through appropriate investigations. We then try to develop an understanding of the potential causes by triangulating all that information and introduce an intervention to remedy it. We may then follow up the patient and monitor for adverse effects. By doing the follow-up we may repeat some of the investigations we did at the beginning. This patient journey can be seen as a process and it is the improvement of processes with which the methods Lean and Six Sigma are concerned. What are lean and six sigma? Lean and Six Sigma are two approaches that originated in manufacturing industries. Both provide a systematic approach to quality improvement. Within both is a series of tools to reach that objective, with some overlap between the tools. The two are often combined to form an approach labelled Lean Six Sigma. Lean was developed in the 1950s by Toyota. The approach focuses on looking at what adds value in a process and aims to eliminate waste and improve the speed at which that process is carried out. Lean principles can be summarised as:
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Applying production-line methods to PBC | Practical Commissioning Article | Pulse Today

30/11/12 6:05 PM

Understanding the customer and their perception of value. Understanding the value stream of the process. The value stream is what you're left with when wasteful steps are removed. Streamlining the process to remove waste and enabling the value to flow. Letting the customer pull the value through the process according to their needs. Continuously pursuing perfection. Six Sigma was developed at Motorola in the 1980s and aims to reduce variation and improve quality by reducing the defect rate in processes. It follows a five-step framework to define, measure, analyse, improve and control processes. How do we reduce variation and defect rates in healthcare? In the clinical process, the defect' is an unsatisfactory outcome for the patient anything from an adverse event to death. There's no denying that healthcare is complex. What quality improvement processes such as Six Sigma or Lean offer is a framework to understand that complexity, to break the issues around healthcare into smaller, more manageable units and to understand the root causes of the problems. We know as clinicians that if we just look at symptoms we don't get a cure. The cure comes once we have made a diagnosis and treated the root cause of the illness. Exactly the same applies to quality improvement. Six Sigma looks at trying to limit variation. As healthcare is more complex, the standard in terms of how much we try to reduce variation would perhaps be less than in the manufacturing industry, but the same principles apply to the way we can do that. It's about standing back and looking at the whole system and the whole process. One of the key things both Lean and Six Sigma start with is understanding the customer, seeing what their needs are and what their perception of value is. The customer' may be the patient, but may also be stakeholders such as commissioners. Applying a combination of the methods Lean Six Sigma to healthcare involves mapping out the steps of the patient journey in detail, questioning which of the steps are really necessary and using information measurement for each of the steps to build a step-by-step picture of the route for these patients. Once this is done you can identify unnecessary steps and start removing these to streamline the process. When this is done in manufacturing industries, often only about 15% or 20% of the steps add any actual value, which gives a huge potential for removing those that are not necessary. That could happen in the health service, although you may need to have some steps that do not appear to have added value because of internal organisational issues. How would I go about applying Lean Six Sigma to PBC? The first step is understanding what these approaches are and what they have to offer (see below for sources). There are two key scopes for using Lean Six Sigma in commissioning. One is in improving the processes of commissioning within the commissioning organisation. The other is in designing new services and new pathways, or redesigning existing ones. Six Sigma has an approach that is often called Design for Six Sigma, which is really well suited to doing this. Listening to the voice of the customer brings the following steps in the approach into focus and if, for example, the voice of the customer is that continuity in care is important, then the process is analysed with that in mind. How would it enhance our commissioning? World-class commissioning talks about investing NHS funds to secure the maximum improvement in health and wellbeing outcomes from the available resources. Lean Six Sigma gives commissioners the opportunity to improve their own commissioning processes. They can start to think about the voice of their customer. In commissioning it is important to involve patients, public and staff and in Lean Six Sigma that is the first step. World-class commissioning says clinical engagement is critical to the success of commissioning and Lean Six Sigma provides the mechanism for getting real clinical buy-in. How do you tackle resistance from those involved in the processes?

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Applying production-line methods to PBC | Practical Commissioning Article | Pulse Today

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One of the problems is obviously getting acceptance from those in the organisation. Communicating with people on the front line is crucial, as is empowering them. One of the key principles of Lean is continuous quality improvement. To get real transformation in the NHS, part of everyone's job needs to be identifying what's working and what isn't working and understanding that it's alright to try to improve it. Once people are involved in change themselves they take ownership. Can you give me some success examples? There are many examples of these processes being used successfully, both within the NHS and internationally. Bolton Hospitals NHS Trust has really taken this approach on board as a way of working. One example is in the pathology department, where the team reduced the number of steps in the process of handling a blood sample from 309 to 57. The distance walked by staff was reduced by 80%, the time taken to process endocrinology and haematinics samples was reduced from between 24 and 30 hours to between two and three hours, the same work was being done by fewer staff and the space needed by the department was reduced by 50%. In another hospital, a radiology department worked from the position of the GP as customer' and reduced the turnaround for reporting on plain X-ray films from two weeks to two days. In my practice Lean Six Sigma is becoming our philosophy. We're using it right across the organisation with about 40 projects on the go at the moment, for example in improving telephone access, management of pathology results in the practice and improving continuity of care for patients, as well as in HR and finance processes. Tangible benefits are seen in terms of finances as removing waste often brings efficiency savings and also in improving quality and adding value to the customer. We keep hearing about waste in the NHS but where's the scope for stopping it? There is indeed a huge amount of waste in the NHS, and Lean Six Sigma is about finding out where the waste is. Lean identifies seven categories of waste: overproduction, waiting, transportation, overprocessing, inventory, motion and correction. In the health service, waiting is a waste, results not being available at the time you need them is a waste and correcting that chasing around for results or repeating the test is also a waste. I strongly believe that the principles of what we do in our everyday lives with patients can be applied to quality improvement. Dr Paresh Dawda is a GP principal in Bishop's Stortford, Hertfordshire, and a GP trainer for the East of England Deanery Find out more at NHS Institute for Innovation and Improvement (URL=http://www.institute.nhs.uk) Lean Enterprise Academy training and workshops (URL=http://www.leanuk.org) Six Sigma internet Six Sigma resources (URL=http://www.healthcare.isixsigma.com) Case study: removing wasteful steps How to apply production line methods to PBC

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