American Health Quality Foundation

By Donald Bryant

Recently as I was working with various representatives from healthcare sites involved in designing a new process, the term “rapid cycle improvement” was mentioned. The term sounded a bit strange to me, a quality improvement engineer. I had not heard it used outside the healthcare field before, either in manufacturing or service quality improvement fields. Being curious, I googled it and found that most uses of this phrase were in the healthcare field. After a bit further investigation, including seeing if the glossary of quality improvement terms on the American Society of Quality’s website included “rapid cycle improvement (it does not)”, I decided that the term most closely resembled the Lean tools “kaizen” and “kaizen events,” which are very well described in the February 2007 Quality Progress journal of the American Society of Quality. In the interest of standardizing the use of terminology I will define and illustrate the ideas of kaizen and kaizen events as used in the Toyota production system.

Kaizen typically refers to continuous, methodical improvement in an organization. It is best carried out by a team whose members are representatives of users of a process being improved. For instance, an emergency room team trying to improve the handling of patients who are under the influence of alcohol along with some sort of trauma might consist of physicians from the ER, a nurse who handles triaging of patients, a representative of staff who make initial contact with patients waiting for treatment in the ER, and a representative of the county mental health department that manages treatment and funding of facilities of those with alcohol addiction.

Another Kaizen characteristic is that it always adopts data measures to monitor its progress and to standardize the process. Although built upon data-how else would you know if you are actually improving a process or implementing a new process without waste (muda)-the most important characteristic of a Kaizen is the human element; the success of a Kaizen depends upon the interactions of those involved, upon the respect accorded to each team member and others involved in the process. Since healthcare generally does not use its human resources in a democratic fashion, use of Kaizen represents a significant cultural change at a healthcare site. If the cultural changes are adopted, though, the benefits are tremendous. Time is saved by eliminating waste, creativity in solving problems in a process by those in involved is unleashed, patient health and satisfaction greatly improves and the financial returns can be significant.

A Kaizen event is generally a quick or fast improvement event which is scheduled to last a limited amount of time. It is also termed “rapid cycle improvement.” Suppose, for instance, that in a new implementation of delivering medication and drugs from the hospital pharmacy for staff to administer to patients there seems to be an increase in the percent of wrong dosage but the correct medication. A leader in the implementation of the rollout of the new process may schedule a one-hour meeting of representatives involved in the process to brainstorm a solution. Once the best ideas are implemented and the problem solved, the Kaizen event is closed and the newly implemented process continues to be monitored by the leader of the rollout. Closing a Kaizen event is in opposition to a Kaizen which is a continual process. Kaizen events are limited in focus, focusing on one problem generally while a Kaizen focuses on improving a complete process, implementing new ideas to eliminate waste and making use of lessons learned. Most businesses are better served by the continuity of a Kaizen rather than the “put out the fire” response of a Kaizen event. Continue Reading

By Chris Majdi

Quality improvement in health care has developed gradually as emerging ideas have been explored and implemented within various clinical and non-clinical settings. One of the more recent methods of quality improvement which has been introduced into healthcare organizations is Six Sigma. Six Sigma is “a rigorous set of processes and techniques to measure, improve, and control the quality of care and service based on what is important to the customer (Woodard, 2005, p. 229).” The goal of this approach is to bring procedures to defect-free levels by trying to eliminate variation in processes. Defects are seen as any factors which lead to customer dissatisfaction. Many processes in healthcare require a near-zero tolerance for error, especially in the clinical setting. Bringing processes to a level that approaches defect-free can positively impact patient care, safety measures, heath outcomes, efficiency, and cost reduction.

Six Sigma efforts have touched a wide range of functions in health care. Examples of such implementations show that they can be successful in several capacities: medication error, lab turnaround time, supply chain management for supplies, claims reimbursement, nursing retention, patient condition outcomes, and others (Revere and Black, 2003). Though the benefits of these projects are clear, the high level of specificity, analysis, and design can make them quite resource intensive. The resource requirements involved in bringing such projects to fruition is a major challenge. In looking at the literature surrounding this topic at least one article suggests a solution. Revere and Black propose piggybacking Six Sigma onto existing Total Quality Management (TQM) programs. Their underlying rationale is that similar quality efforts can be synergized to achieve better results with less disruption to organizations. “Six Sigma is an extension of the Failure Mode and Effects Analysis that is required by JCAHO; it can be easily integrated into existing quality management efforts (Revere and Black, 2003, p. 377).” Such an approach would involve the integration of Six Sigma into an existing program through detailed data analysis. It would require delving into the current process examination and improvement measures on a more detailed level.

Some TQM programs may lack sufficient data collection and analysis to fully understand process variation. Six Sigma can overcome these challenges through its emphasis on understanding process variation in tandem with implementing change. This aspect of Six Sigma can make TQM more effective. “The work of Six Sigma is not unlike TQM; however, its goals are more aggressive and its methods are better defined (Revere and Black, p. 379, 2003).” Using these two approaches jointly can be valuable in creating successful quality improvement programs.

Though Six Sigma provides a higher level of measurement, this is not the only aspect which can make it successful in healthcare organizations. Enhanced metrics need to be paired with skillful management in order for programs to be designed that are successful in diminishing process variation. Programs must be designed to alter structures and processes to actually produce changes in outcome. Furthermore, methods must be put in place to ensure compliance with these process changes. These tasks become the responsibility of company management and program participants, and the steps involved must be administered effectively in order to be successful. Six Sigma is guided by the DMAIC approach: define, measure, analyze, improve, and control (Riebling and Tria, 2005). Continue Reading

By Donald Bryant

W. Edwards Deming once said, “In God we trust, all others bring data!” That is just what I propose to do in this newsletter. I often speak of how continuous quality improvement programs improve the bottom line at a healthcare site. This idea is throughout my web site. I promote the idea that “Quality pays, it does not cost.” That is, a good quality improvement program based upon population level data not only is not cost neutral, it improves the income and profit at a site. Many healthcare professionals do not believe this. They point at all the regulatory standards for quality, such as those written by JHACO, and believe that quality is actually costing them quite a bit. I have done some extensive research on this topic recently and believe that I can prove this point convincingly to you.

Fortunately there is good documentation of financial outcomes at healthcare sites which use various quality improvement approaches. I am very familiar with two of these-TransforMed’s National Demonstration Project and the Federal Government’s NIST (National Institute of Standards and Technology) Baldrige Award program. Starting in 2006 TransforMed, a subsidiary of American Academy of Family Physicians, began a program to aid in transforming a sample of primary care practices into models of the Patient-Centered Medical Home (PCMH). One group of sites was actively involved with representatives from TransfoMed to adopt the Patient-Centered model and the other group used materials supplied to them by TransforMed to use in a self-directed approach to adopt the model. TransforMed’s CEO, Dr. Terry McGeeney, wrote an article recently (available on the TransforMed website) summarizing the financial impact of the adoption of the PCMH. The results were very positive. The revenue for the assisted sites rose 10.49% on average and the rise in revenue for the self-directed sites was 2.43%. For physicians at these sites personal income rose nearly 14% at the assisted sites and 13% at the self-directed sites. This was achieved while most of these practices were installing electronic medical records. These results are well documented because of TransforMed’s practice change model incorporates strict tracking of financial data.

I am familiar with one such site here in West Michigan that has seen its bottom line swing from the red to the black because of its involvement with the TransforMed national project.

The Baldrige Award is given out each year to competitors in manufacturing, small business, education, healthcare and nonprofits. Those competing for the award must document continual quality improvement in a variety of categories. For healthcare providers there must be demonstrated improvement and achievement in healthcare outcome, patient and other customer-focused outcome, financial and market outcomes, workforce-focused outcomes, process effectiveness outcomes and leadership outcomes. In 2002 SSM Healthcare in St. Louis, the first healthcare recipient of the Baldrige Award, noted that it was able to maintain a AA credit rating over 4 years as it worked on the goals of the Baldrige Award. It increased its market share in St. Louis from 13% to 18% while three of its competitors lost ground. It has also been able to maintain its goal of contributing at least 25% of its operating revenue to charity care at its site. This is very impressive, given today’s marketplace challenges. Continue Reading