The buzz-around-lean-six-sigma-hospitals

You may have heard that Lean Six Sigma is catching on with hospitals and other healthcare providers. This business management strategy specificially addresses process flow and waste issues while focusing on variation and design to promote business and operational excellence. Essentially, Lean Six Sigma helps eliminate defects throughout an organization, which in healthcare can mean preventing medical errors, decreasing mortality rates, reducing lengths of stay, improving patient care, and improving quality.

"Using Six Sigma decreases variation; process outcomes become more predictable and effective. Lean targets the efficiency of processes, decreasing waste and increasing profitability," Marti Beltz, Six Sigma instructor for American Society for Quality and healthcare quality consultant, told FierceHealthcare. "Used together, they produce a synergistic effect not only economically, but also in terms of patient and workforce satisfaction."

Perhaps more importantly, Lean Six Sigma allows hospitals to achieve balance between the seemingly mutually exclusive goals of providing cost-effective, high-quality care. "Other industries struggled with [similar dilemmas] for many years but ultimately discovered that you can indeed have both with the right management and improvement system in place," Charles Hagood, president and founder of Healthcare Performance Partners, told FierceHealthcare.

How does it work in practice? Sometimes, this strategy demonstrates successes in simple ways. "Moving a dressing room out of the imaging room to increase process flow resulted in three times the capacity for mammograms and three times the profits," Beltz said.

And for hospitals interested in concrete return on investment, organizations that have incorporated Lean Six Sigma principles are seeing strong results, Hagood said. For example, a new facility reduced the required square footage by 15 percent while increasing volumes, thereby improving deposit turnaround to 90 percent of all remittances within six hours and increasing the amount of CT scans per day by 22 percent without adding equipment or staff. Plus, some mid-sized hospitals have saved $10 million within two years by using the business management strategy, he added.

So how can other hospitals achieve similar results within their organization? Described as a "full contact sport that you can only learn by getting your hands dirty and 'doing it'," Hagood advised hospital leadership to examine daily management systems and constantly look for waste and variation to eliminate. "Ultimately, the best way to prepare management for executive positions using Lean Six Sigma principles is to create a learn-by-doing environment and to model the approach as the existing leadership leave."

The key to success, according to Beltz, is ensuring that senior management has a solid understanding of Lean Six Sigma's basic concepts, process, and requirements. Only then can the rest of a hospital's workforce deploy these methodologies. "The most successful organizations use a combination of a small group of internal consultative experts and very basic quality training for everyone," she said.

Like any other silver bullet promising a quick and easy fix to a complicated problem, Lean Six Sigma has its own obstacles--namely, physician resistance. "Physicians can be reticent to implement Six Sigma because the methodology has been incorrectly associated with huge resource output, their time specifically," Beltz said.

That's why Hagood warns hospitals about using Lean Six Sigma as a cram down. "If Lean Six Sigma is deployed correctly, [physicians] will see the value and will want to become a part of the equation," he explained. "If the value is seen and the hospital's commitment is evident, in most cases, the physicians will not be resistant over the long term."

Beltz added that hospitals should work to understand the sources of physician resistance, such as valuing intuition over disciplined problem solving to help overcome them. "The most compelling argument to get physicians to try Lean Six Sigma is to help them understand that when stripped down to its roots, Lean Six Sigma is based directly upon the scientific method--a concept well-studied and advocated in medical school," she said.

Although it might not be a cure-all for the industry's woes, hospitals could benefit from such a quality improvement initiative and its effects throughout provider organizations. --Dina

Dina Overland is the editor of FierceHealthPayer, a sister publication of FierceHealthcare.

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Value Chain Analysis Achieving Excellence in the Things That Really Matter

Value Chain Analysis is a useful tool for working out how you can create the greatest possible value for your customers.

In business, we're paid to take raw inputs, and to "add value" to them by turning them into something of worth to other people. This is easy to see in manufacturing, where the manufacturer "adds value" by taking a raw material of little use to the end-user (for example, wood pulp) and converting it into something that people are prepared to pay money for (e.g. paper). But this idea is just as important in service industries, where people use inputs of time, knowledge, equipment and systems to create services of real value to the person being served – the customer.

And remember that your customers aren't necessarily outside your organization: they can be your bosses, your co-workers, or the people who depend on you for what you do.

Now, this is really important: In most cases, the more value you create, the more people will be prepared to pay a good price for your product or service, and the more they will they keep on buying from you. On a personal level, if you add a lot of value to your team, you will excel in what you do. You should then expect to be rewarded in line with your contribution.

So how do you find out where you, your team or your company can create value?

This is where the "Value Chain Analysis" tool is useful. Value Chain Analysis helps you identify the ways in which you create value for your customers, and then helps you think through how you can maximize this value: whether through superb products, great services, or jobs well done.



Note:

This article looks at a simple approach to using value chains. A more structured approach was developed by Harvard Business School professor Michael Porter (also creator of the 5 Forces tool) in his book "Competitive Advantage". You can find out more about this version by clicking here.



How to Use the Tool:

Value Chain Analysis is a three-step process:

Activity Analysis: First, you identify the activities you undertake to deliver your product or service;

Value Analysis: Second, for each activity, you think through what you would do to add the greatest value for your customer; and

Evaluation and Planning: Thirdly, you evaluate whether it is worth making changes, and then plan for action.

We follow these through one-by-one:-

Step 1 – Activity Analysis

The first step to take is to brainstorm the activities that you, your team or your company undertakes that in some way contribute towards your customer's experience.

At an organizational level, this will include the step-by-step business processes that you use to serve the customer. These will include marketing of your products or services; sales and order-taking; operational processes; delivery; support; and so on (this may also involve many other steps or processes specific to your industry).

At a personal or team level, it will involve the step-by-step flow of work that you carry out.

But this will also involve other things as well. For example:

How you recruit people with the skills to give the best service.

How you motivate yourself or your team to perform well.

How you keep up-to-date with the most efficient and effective techniques.

How you select and develop the technologies that give you the edge.

How you get feedback from your customer on how you're doing, and how you can improve further.



Tip:

If you carry out the brainstorming behind the Activity Analysis and Value Analysis with your team, you'll almost certainly get a richer answer than if you do it on your own. You may also find that your team is more likely to "buy into" any conclusions you draw from the exercise. After all, the conclusions will be as much theirs as yours.



Once you've brainstormed the activities which add value for your company, list them. A useful way of doing this is to lay them out as a simplified flow chart running down the page – this gives a good visual representation of your "value chain". You can see an example of this in Figure 1 below.

Step 2 – Value Analysis

Now, for each activity you've identified, list the "Value Factors" – the things that your customers' value in the way that each activity is conducted.

For example, if you're thinking about a telephone order-taking process, your customer will value a quick answer to his or her call; a polite manner; efficient taking of order details; fast and knowledgeable answering of questions; and an efficient and quick resolution to any problems that arise.

If you're thinking about delivery of a professional service, your customer will most likely value an accurate and correct solution; a solution based on completely up-to-date information; a solution that is clearly expressed and easily actionable; and so on.

Next to each activity you've identified, write down these Value Factors.

And next to these, write down what needs to be done or changed to provide great value for each Value Factor.

Step 3 – Evaluate Changes and Plan for Action

By the time you've completed your Value Analysis, you'll probably be fired up for action: you'll have generated plenty of ideas for increasing the value you deliver to customers. And if you could deliver all of these, your service could be fabulous!

Now be a bit careful at this stage: you could easily fritter your energy away on a hundred different jobs, and never really complete any of them.

So firstly, pick out the quick, easy, cheap wins – go for some of these, as this will improve your team's spirits no end.

Then screen the more difficult changes. Some may be impractical. Others will deliver only marginal improvements, but at great cost. Drop these.

And then prioritize the remaining tasks and plan to tackle them in an achievable, step-by-step way that delivers steady improvement at the same time that it keeps your team's enthusiasm going.



Tip:

If you have a strong enough relationship with one or more of your customers, it may be worth presenting your conclusions to them and getting their feedback – this is a good way of either confirming that you're right or of getting a better understanding of what they really want.



Example:

Lakshmi is a software development manager for a software house. She and her team handle short software enhancements for many clients. As part of a team development day, she and her team use Value Chain Analysis to think about how they can deliver excellent service to their clients.

During the Activity Analysis part of the session, they identify the following activities that create value for clients:

Order taking

Enhancement specification

Scheduling

Software development

Programmer testing

Secondary testing

Delivery

Support

Lakshmi also identifies the following non-client-facing activities as being important:

Recruitment: Choosing people who will work well with the team.

Training: Helping new team members become effective as quickly as possible, and helping team members learn about new software, techniques and technologies as they are developed.

Lakshmi marks these out in a vertical value chain on her whiteboard (you can see the first three client-facing activities shown in the "Step 1: Activity Analysis" box in Figure 1 below):



Next, she and her team focus on the Order Taking process, and identify the factors that will give the greatest value to customers as part of this process. They identify the following Value Factors:

Giving a quick answer to incoming phone calls.

Having a good knowledge of the customer's business, situation and system, so that they do not waste the customer's time with unnecessary explanation.

Asking all the right questions, and getting a full and accurate understanding of the customer's needs.

Explaining the development process to the customer and managing his or her expectations as to the likely timetable for delivery.

You can see these in the "Value Factors" column of figure 1.

They then look at what they need to do to deliver the maximum value to the customer. These things are shown in the Figure 1's "Changes Needed" column.

They then look at what they need to do to deliver the maximum value to the customer. These things are shown in the Figure 1's "Changes Needed" column.

They then do the same for all other processes.

Once all brainstorming is complete, Lakshmi and her team may be able to identify quick wins, reject low yield or high cost options, and agree their priorities for implementation.



Key Points:

Value Chain Analysis is a useful way of thinking through the ways in which you deliver value to your customers, and reviewing all of the things you can do to maximize that value.

It takes place as a three stage process:

Activity Analysis, where you identify the activities that contribute to the delivery of your product or service.

Value Analysis, where you identify the things that your customers value in the way you conduct each activity, and then work out the changes that are needed.

Evaluation and Planning, where you decide what changes to make and plan how you will make them.

By using Value Chain Analysis and by following it through to action, you can achieve excellence in the things that really matter to your customers.

Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy:

Abstract

Objective

To evaluate if direct physiotherapy assessment and management of patients presenting to emergency departments with musculoskeletal injuries (primary contact physiotherapy) results in reduced length of stay without any increase in adverse effects compared with secondary contact physiotherapy, where patients are seen by a physiotherapist after initial assessment by a doctor.

Design

Prospective non-randomised controlled trial.

Setting

Three metropolitan emergency departments.

Participants

Adults (n=315) presenting to emergency departments with peripheral musculoskeletal injuries were allocated to primary or secondary contact physiotherapy; 306 participants completed the study. Patients with serious pathology, open fractures and spinal pain were excluded.

Intervention

A single episode of physiotherapy.

Main outcome measures

Primary outcome measures were patient length of stay, waiting time and treatment time. Secondary outcome measures were re-presentations to the emergency department, imaging referrals, patient satisfaction and emergency department staff acceptance.

Results

Primary contact physiotherapy resulted in a reduction in length of stay of 59.5minutes [95% confidence interval (CI) 38.4 to 80.6] compared with secondary contact physiotherapy, with a reduced waiting time of 25.0minutes (95%CI 12.1 to 38.0) and a reduced treatment time of 34.9minutes (95%CI 16.2 to 53.6). There were no differences between the groups in imaging referrals or re-presentations. Patients strongly agreed (≥82%) that they were satisfied with their management, and 96% of emergency department staff agreed that primary contact physiotherapists had appropriate skills and knowledge to provide emergency care.

Conclusion

Experienced musculoskeletal physiotherapists working in emergency departments can be the first point of contact for patients with simple, semi-urgent and non-urgent peripheral musculoskeletal injuries, resulting in decreased waiting times and length of stay for patients without any adverse effects.

Is pelvic floor muscle training effective when taught in a general fitness class in pregnancy? A randomised controlled trial

Cite this article

Abstract

Objectives

Pelvic floor muscle training (PFMT) following vaginal assessment of correct contraction can prevent and treat urinary incontinence in the peripartum period. The aim of this study was to evaluate the effectiveness of PFMT instructed in a general fitness class for pregnant women.

Design

Single-blind randomised controlled trial.

Setting

University-conducted primary care study.

Participants

One hundred and five sedentary primiparous women randomised to a general fitness class including PFMT (n=52) or a control group (n=53). Ten and 11 women were lost to follow-up in the exercise and control groups, respectively.

Intervention

Twelve weeks of training comprising twice-weekly 1-hour fitness classes including three sets of eight to 12 maximal pelvic floor muscle contractions. The control group received usual care.

Outcome measure

Number of women reporting urinary, flatus or anal incontinence.

Results

No significant differences were found in the number of women reporting urinary, flatus or anal incontinence between the exercise group and the control group during pregnancy or at 6 weeks post partum.

Conclusions

No effect of PFMT was found when the exercises were taught in a general fitness class for pregnant women without individual instruction of correct PFM contraction. Low adherence and the small sample size may have contributed to the negative results. Further studies are warranted to assess the effect of population-based PFMT in the prevention of urinary and fecal incontinence.

Accounting for Time Making Best Use of a Precious Resource

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How are you using timesheet data?

© iStockphoto/craftvision

However compensation is calculated in your organization, people's time costs money. That's why employers need to know that their people are at work for the right hours. It's also why, in many cases, they need to know what their people are working on when they're there.

That's why factory and shop staff have to clock in and out, why lawyers and management consultants fill in timesheets, and why project managers running multiple projects allocate the proportion of their time spent on each project to different project codes.

Without an appropriate time recording system in place, you have no way of billing for hours worked, you have no way of improving the accuracy of fixed price quotations, and you can't tell which projects are profitable, and which ones you should never rerun again.

In this article we'll look in detail at the benefits of accounting for time, we'll discuss the various approaches to time recording that organizations can use, and finally we'll show you what you need to consider when deciding what type of time recording is right for you.

Why Record Time?

For Payroll

In its most basic form, workers track the time they spend at work by using a time card to "clock in" on a machine. The machine records the hours worked, and the information is sent to payroll for processing.

Clocking in is generally used in factory, retail and other environments where there is traditionally a certain mistrust of "shop floor" staff: it implies that they can't be trusted to arrive on time and work a full shift. On the other hand, the practice can protect both employees and their supervisors: by clocking in, an employee can be confident that they won't be falsely accused of late-coming, and they also know that the system will immediately pick up on any overtime payments they're due. Meanwhile, supervisors are freed from "roll call" duties, and can focus on more value-added work.

For Invoicing

Law firms, accountants, consultancies, and other professional services firms(whose principle activity is to "sell time") need their staff to track and account for time accurately, so that they can invoice their clients correctly.

To Identify Productivity

Professional services firms also want their people to maximize the amount of time they devote to generating revenue, while minimizing the amount of time spent on administrative duties. By tracking time, they record how productive each person is by measuring the proportion of each day that he or she spends on chargeable work.

Another aspect of this relates to when work is sold to the client at a fixed price: if the consultant or lawyer doing the piece of work can do it faster (at the same quality) than a colleague who is on the same salary, they'll obviously be able to move on to the next project sooner, and earn more fee revenue for their firm. Again, time recording reveals people's productivity levels.

Finally, recording the time spent on fixed price work allows the firm to analyze how accurate their estimating process is. If it turns out that work is regularly taking longer than expected, even when highly efficient people are doing it, this obviously eats into profits. On the other hand, if the reverse is true, businesses may lose work because their bids are uncompetitive.

To Understand Internal Costs

Even when work is not being charged out to clients, organizations need to know what different activities cost. This applies both to project-based work, and to "business as usual" activities such as accounts processing.

Time recording in these cases helps organizations identify what proportion of their costs are overheads and what proportion operational, and how this changes over time. They can calculate the full cost of a marketing campaign. Or they can assess whether a non-strategic function such as payroll might cost-effectively be outsourced.

By collecting this type of information, you're also in a better position to plan future projects. Using time-tracking data gives you a more accurate picture of how efficiently your team will perform a set of tasks.

Finally, time tracking allows you to identify trends. You can see what categories of work are being done more or less. Ultimately, the more information you gather about your organization, the better you're able to understand and manage your business.

Types of Timekeeping Systems

• Card clocking – People often think of this system first. Traditional time clocks used punch cards that were stamped with the time and date at the beginning of a worker's shift, and then stamped again at the end. Time cards were then sent to payroll to be processed each pay period.
• Today, this information is usually sent electronically, and can be tracked very accurately. There are portable systems that can be taken to different work sites – for example, in the construction industry. There are even biometric devices that use fingerprint recognition. This type of system provides added assurance that the person "clocking in" is actually in attendance.
• Time sheets –Time sheets are used to track items like attendance, break time, project time, and billable hours. They may include hourly rates and expense information. This then helps you evaluate time by worker, task, project, and client. Time sheets are very customizable, and can be tailored to meet the exact needs of your organization. They can either take the form of a spreadsheet, or a special time-tracking application that's part of the organization's accounting software.
• Computer-based time recording – These are computer applications that track the time someone spends working on specific projects or with particular clients.
• There are two categories of software. The first type allows you to switch back and forth between tasks. This way, you can track hours per project, distinguish between billable and non-billable tasks, manage absences, calculate overtime, and print reports automatically. (Wikipedia has a comparison pageof some notable time-tracking systems.)
• The second type runs in the background of your computer and records exactly what you're working on each second of the day. The software operates by continuously taking screen shots, and it allows you to quickly recall what you worked on, and for how long. (TimeSnapper has a free version that you can download.)

Do You Need a Timekeeping System?

Some organizations have no choice but to use a timekeeping system. If you charge time to different clients or different projects, then you must keep track of the hours you spend. Clients often want to know that you have a reliable system in place, so that you can bill them fairly.

For organizations that have a choice, it's important for the benefits of timekeeping to outweigh the costs. Keeping track of workers and checking on what they're doing every minute of the day is not reason enough to establish a timekeeping system. If you're tracking time because of a lack of trust, then there are probably much larger issues to address.

Timekeeping systems can be expensive. There may be an up-front cost of purchasing equipment and software, and there's also the cost associated with taking time to track your time. It's therefore important to conduct a propercost/benefit analysis to determine whether you need a timekeeping system.

Even the simplest spreadsheet solutions take time for workers to complete on a regular basis. If you ask workers to track how they spend their time, make sure that information is used in some meaningful way. Before you ask workers to track their time, make sure that you know why you want to track it, how you'll use the information, and whether the analysis will lead to changes and improvements.

Key Points

In many organizations, people's time is the most costly resource. It is therefore often essential to monitor the use of time within your organization. By doing this, you can see how and where time is being spent, and you can identify trends in its use. From there, you can improve productivity, profitability, and customer service.

There are many timekeeping options available, from simple manual time sheets to sophisticated software solutions. Each has its benefits and associated costs. Before implementing a timekeeping system, analyze the costs versus the benefits to determine what's best for your organization.

The RATER Model Five Ways to Measure Service

The RATER Model

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Five ways to assess your service.

© iStockphoto/Neustockimages

How do you assess the quality of the service that you give to your customers?

You might ask focus groups or do a customer satisfaction survey. Or you could look at the number of complaints you get, or analyze the time it takes to answer customer queries.

While all of these can be useful for assessing what people think of your service, using unstructured approaches like these can lead you to miss areas that are important to your customers.

This is where the RATER Model can help. This useful tool highlights the areas that you need to focus on to provide great customer service. In this article, we'll explore the model, and we'll look at how you can use it to improve the service that you provide to your customers.

Tip:
Remember that customers can be internal to your organization, as well as external. So this model is relevant in a wide range of scenarios.

About RATER

The RATER Model was created by professors Valarie Zeithaml, A. Parasuraman, and Leonard Berry, and published in their 1990 book, "Delivering Quality Service."

The model highlights five areas that customers generally consider to be important when they use a service. These are:

• Reliability – your ability to provide your promised service consistently, accurately, and on time.
• Assurance – the knowledge, skills, and credibility of staff; and their ability to use this expertise to inspire trust and confidence.
• Tangibles – the physical evidence of the service you provide. This could be buildings or offices, your equipment, employees, and the communication or marketing materials that you use.
• Empathy – the relationship between employees and customers.
• Responsiveness – your ability to provide a quick, high quality service to your customers.

By focusing on these five areas, you can analyze and improve service.

Tip:
The RATER Model is a simplified version of the SERVQUAL Model, which was first created in 1988. Nowadays, you must also consider the state of your online presence, as well.

Depending on the importance of your online channels to your business, you can consider this under the tangibles heading (even though your online presence isn't strictly "tangible"), or you could have a separate area for this. (We add questions relating to these in below, even though these were not part of the original RATER model.)

How to Use RATER

A good way of using the RATER Model is to carry out a Gap Analysis using each of the five dimensions. You can then come up with a plan for improving the way that you serve your customers.

To do a Gap Analysis, you identify the following in each of the five areas:

• Future state – the "place" you want to be to provide exceptional service.
• Current situation – how you currently provide your service.
• Next Actions – how you'll move from your current situation to your future state.

You can use the following questions as a starting point for thinking about each area:

Reliability

• How well do you provide the service that you've promised to your customers?
• Are your systems and processes robust and reliable?
• Is service delivery consistent and timely, across all service channels (including online)?
• Could you improve the quality of your service in any other way?

Assurance

• Do staff have the skills and knowledge needed to deliver a good service?
• Do your people need any further training or development?
• Do staff inspire trust in customers?
• Is your service safe and secure?

Tangibles

• Is the physical evidence of your service (products, packaging, marketing materials, website, offices, staff appearance, and so on) attractive and appropriate for your customers?
• Are your website FAQs useful, comprehensive, and up to date? And can people talk to a human being if their questions haven't been answered, or if your website is broken?
• As well as managing traditional channels and your website, are you properly handling queries and feedback through Twitter, Facebook, LinkedIn and other online services?
• Does physical or virtual evidence fit with your organization's brand?

Empathy

• Do your people build good relationships with customers?
• Is all communication with customers clear and timely?
• Do staff show empathy with customers? Do they understand why empathy is essential for providing a great service?
• Do your people genuinely care about customer needs?
• Are staff able to see things from a customer's point-of-view?

Responsiveness

• Do you provide a prompt service, which is easy to access?
• Do you manage complaints and feedback appropriately?
• Are staff always willing and able to help customers?
• Do you resolve customer issues and problems satisfactorily, and in good time?

When you identify your future state and your current situation, it's important that you talk to your customers to understand their experiences and expectations fully.

Where you can't talk to customers directly, use tools such as Customer Experience Mapping to see your service from their perspective. You can also use Reverse Brainstorming to explore possible service improvements, and Benchmarking to compare your performance with similar organizations or services.

Tip:
There is arguably some crossover between some of the elements of the RATER Model. Don't worry about this – just aim to do a thorough analysis in each of the five areas.

Key Points

The RATER Model was created by professors Valarie Zeithaml, A. Parasuraman, and Leonard Berry. It highlights five areas that customers consider important when they use a service. These are:

1. Reliability.
2. Assurance.
3. Tangibles.
4. Empathy.
5. Responsiveness.

You use the model by doing a Gap Analysis in each of the five areas. From this, you can plan how you'll improve the service you give to your customers.