03 Aug How to transform your operations through quality improvement projects
The quality improvement project has a strong foundation in Lean Six Sigma methodology. Although there are parallels, they are not the same. But by applying a Six Sigma process improvement framework, there is much to gain in completing a successful quality improvement project.
The quality improvement project is a uniquely American type of research or study. Not peer reviewed, quality improvement projects (QIPs) are often presented in the form of posters at various medical symposia around the country. While compared to other research projects, a poster or QIP may seem simple, they are not easy to pull off.
There is not necessarily a formal process when undertaking a QIP and many clinicians approach them differently. Just type in “quality improvement project” into Google and you will see a litany of methods, advice, papers, and direction. In this article we describe first the importance of a QIP, how to apply a Six Sigma methodology to the process, some key tips, and how to effectively partner with your vendors to carry out these projects.
To start, why should you even consider launching a QIP? Two reasons.
The first, so that something can be improved. The goal of any organization is to get better. Certainly, this is the case in a hospital. If you can continue to improve operations or clinical practice, then it’s a win-win for the bottom line and for patients.
Second, notoriety. Whether personal or for the institution, when a hospital is constantly publishing studies, even in the form of posters, there is a certain amount of recognition that comes with it. If an individual is publishing and publishing strong findings, there may be opportunities to work with industry partners, become a speaker, or open other career opportunities.
Hospitals regularly employ consultants. Often billed as healthcare experts, consultants are typically business experts with an understanding of hospital operations. Though there may be some instances where they can help, if properly directed, a clinician or other hospital personnel may be equally as effective as a consultant. Especially when equipped with the resources to carry out a successful quality improvement project.
So, in addition to the two reasons why you should consider a QIP, properly employing one, may save money for the exercise, not just the outcome.
Now that we have established that QIPs are good for business and careers, let’s look at how to apply the Lean Six Sigma process to a QIP.
The Six Sigma 5-Phase Process
First, a word on Lean Six Sigma if you are unfamiliar with the term. Lean manufacturing can be traced back to Henry Ford and was more formally developed in the 1930’s by Toyota as a means to streamline operations and improve processes. Six Sigma was developed in the 1980’s by Motorola to reduce waste and improve operations. Today, the principles are intertwined and regarded as one system with different subcomponents to improve any process and drive out waste.
There is a simple framework in Six Sigma called the DMAIC framework, pronounced Duh-may-ick. It is a 5-phase process utilized in a process improvement project. The phases are Define, Measure, Analyze, Improve, and Control. Let’s take each one in turn.
This may be one of the most important aspects of the project. If the goal of the project is not well defined, then it can be extremely difficult to get the outcome you are looking for. It has been said that a problem well defined is a problem half solved. But you must be careful to be specific while not implying the cause of the problem in the statement.
Here is an example of a poor problem statement: Revenue is down because billing cycles are taking too long.
It’s a poor statement because it assumes the cause, it is broad, it is not actionable, and is too vague.
Here is a better version: Over the past 9 months billing cycle times have increased from 3.5 weeks to 6.7 weeks. The target billing cycle time is 2.8 weeks. Billing cycle time has been associated with $550,000 in increased cost since October 2018.
The second statement is very specific. It does not assume any causes or solutions. But as you can see, the problem is half solved. We know the cost associated with higher billing cycle times and our target time. Now we just need to find out what exactly is going on and how to improve the process.
The next phase is measure. During this phase we are still not doing anything, we are simply assessing. This may be one of the most challenging steps. You have defined the problem, now you want to go and attack it! But if you do that, you may miss something. You may be able to get billing cycle times down a week or two, but not back to target levels. And you may introduce more cost in the system. You must measure before you can find the root cause of the problem. You also have to measure to know if your process improvement worked in the first place.
To begin measuring, have a solid data collection plan. In our example you would measure the current state. How long does each step of billing take, what are the steps, who is involved in the process, etc. We also want to make sure the data is reliable. Sometimes interfering or telling someone you are going to track them through a process artificially changes the baseline data. An accurate baseline is critical.
If you were excited to finally tackle the problem, well bad news. Not yet. Abraham Lincoln once said that if he had 5 hours to cut down a tree, he would spend the first 3 sharpening the axe. In phase 3, we are still sharpening the axe.
Now that we have the data and understand the process, we can dive into analyzing what is wrong with it. There are a myriad of tools you can use to identify the cause of the issue. One of my favorites is the “5 Whys.” If you have seen the movie Uncle Buck or spent time with a 6-year-old you know this game well. If I say, “It took us 2 months to complete this one billing cycle.” You would then ask why, 5 times until you can get down to a root cause.
Let’s look at an example in practice.
The billing cycle took 2 months.
1. Why? It took patients longer to pay.
2. Why? We had to reissue bills and follow up more than usual.
3. Why? There was a mix up with some of the statements and patients were not being charged properly.
4. Why? We just changed to a new online bill pay system and people have been entering information incorrectly.
5. Why? They were not trained on the new system.
It will never be this easy in real life, but you get the point. Using a host of tools, including fishbone diagrams, Pareto charts, histograms, interviews, and other fun tools you can get to the root cause of the problem you are trying to solve. Keep in mind there may be a couple of main causes to your problem. Focus on them in kind to improve the process.
After you have identified the root cause of your problem, it is time to move to Phase 4, Improve. Hooray! Its time to do something! We can identify a solution, implement it, and check to see if it is working.
Essentially, you are trying to solve the root cause of your problem. So, in the above example, we learned that we implemented a new online bill pay system. Well spoiler, we may need to dig into that just a little more. Is it a training issue? Is the new system making errors? Do people hate it and are purposefully misusing it, so we go back to the old system? Probably not the last one, but maybe the first!
Let’s say after some interviews and brainstorming sessions we determine its time to implement a specific training to solve the problem. We select a pilot group of people (always important to start small and test) to go through training. Its 2 hours and online. After they complete the training, we collect additional data on their billing cycle times to see if they improve. Lo and behold, their average time is 2 weeks! Hooray, in this incredible, unrealistic, and simplified example, we did it!
Control is the final and most often overlooked phase in the process. Have you ever been to the gym? Its New Years and you decide to get in shape. You go for 6 months and get in amazing shape! Then you stop going. What does your body do? It slips back to its old baseline.
That is the exact danger after a process improvement project concludes. We know our solution works, we test it, roll it out, but then people stop doing the training. Slowly our billing cycle times creep back up.
If the process you just improved begins slipping back to the baseline, then we have not done a good job of controlling the process. Mechanisms need to be put in place that keep our solution working long term, measures the slippage, and triggers an event if our output slips back to pre-improvement levels. We should not let our hard work go to waste.
Applying DMAIC to QIPs
Now that you are essentially Six Sigma certified, how does all of this apply to a QIP? Well in short, you basically just walked through a QIP. As we indicated before, there is no hard and fast method to carrying out a QIP. We just need a process or outcome we want to improve and then figure out a way to improve. This method may be robust, perhaps even overkill, but the principles should be applied. Strong definition of a problem to tackle is always critical. Something unknown or unmeasured cannot be improved. Analysis will help identify what to improve within the process. Then a solution is tested, implemented, and instituted in a long term, meaningful way.
Sorry there is not more of a revelation in this section. But if you can apply the principles of the DMAIC process to a QIP, then you are in good shape. Here is a great resource overview of the DMAIC process.
A QIP Secret
One secret to carrying out a quality improvement project is to involve your vendors when possible. As we previously wrote about, partnering with vendors may help improve outcomes. They have tremendous resources behind them, including clinicians, and in some cases Six Sigma black belts, people whose sole job it is to improve processes. There have even been cases where companies take on process improvement projects for hospitals at no charge and present them with the data to improve their operations.
The secret to getting that done? Ask. Go to a rep and say, we are having trouble with x, I would like to do a QIP, who do you work with that could help me with that? Guaranteed any problem in the hospital, there is a rep who would be all over the opportunity.
QIPs can be very intimidating. It seems like a lot of extra work and complicated. But with a simple framework and a well-defined problem statement, anyone can tackle a QIP. They are incredibly beneficial to facilities, to patients, and to professional careers. And if you happen to be a little bit of a nerd, like us, they are even a little fun.