Preface
Overview
Healthcare over the past decade has been required to undergo significant fundamental change—change that will likely continue for the foreseeable future. Most healthcare organizations have risen to the challenge, yet many are struggling to achieve the desired success. The intent of this book is not to examine the external factors driving these changes; there are many other texts dedicated to that particular task.1 Rather, the focus here is on examining the internal factors causing the struggles: the organizational capabilities of structuring and executing change through performance improvement methodologies—specifically, one of the more successful ones, Lean Sigma.
1. One such example is Escape Fire, by Donald M. Berwick. Also, the Commonwealth Fund releases regular updates on the state of healthcare in the United States relative to other countries in its Mirror, Mirror report.
Lean and Six Sigma are well-understood change concepts outside healthcare. With well over 20 years of success in multiple industries, the results speak for themselves. Major corporations show savings in annual reports measured in hundreds of millions of dollars and even billions of dollars. Finally the push is being made into healthcare. Unfortunately, as Lean Sigma makes headway in healthcare, there seem to be so many misconceptions about what it really is—for example, that it is merely a toolkit akin to existing improvement methods. These many misconceptions present problems in that they remove many of the key facets that make Lean Sigma different, the same ones that in practice make it work successfully.
The intent here is to explain how the Lean Sigma approach, so successful in other industries, can be readily transferred to healthcare and give comparable, if not greater, results.
This book is in no way meant to be a technical text. Most guides at this point switch to “stat speak” and both confuse and alienate the reader with technical jargon. This is not the essence of Lean Sigma. Lean Sigma is not rocket science. Practitioners of Lean Sigma don’t need a deep technical or statistics background. Experience shows that often the best practitioners do not have a statistics background at all.
The book is predominantly about change and how to manage it at an organizational level. Lean Sigma is a change initiative. It is designed as a means to improve a business. Any business. It draws from the successes of previous initiatives and adds critical elements where previous initiatives failed. In simple terms, Lean Sigma is a business performance improvement methodology that
• Focuses on processes
• Aims to find root causes versus merely tackling symptoms
• Makes change via well-scoped projects
• Ensures that projects are the right projects by linking them directly to the business goals
• Ensures that the right resources are involved at all levels
• Ensures that barriers are identified and removed
• Carefully tracks progress to ensure success
• Utilizes individuals drawn from the organization to become a pool of well-trained change resources to lead projects
• Utilizes consistent, well-defined roadmaps to solve process problems using data, not speculation or gut feel
• Ensures that robust controls are in place to sustain any gains
This list makes absolute sense—nothing in this book should seem to be more than common sense. There are no smoke and mirrors involved—in fact no magic at all. This is just a robust method for making business performance improvement.
So why then do so many in healthcare falter when they come to apply such a commonsense approach? Unfortunately there are multiple reasons for this.
• It does require an investment of leadership, which often goes unrecognized.
• It doesn’t fit the existing change model, and leaders don’t know how to integrate it into their business.
• Practitioners of existing (typically quality) approaches, both inside the organization as well as external consultants, try to position this as something they were already doing and thus never really progress.
• It is perceived as an extension of existing methods and therefore does not get the appropriate attention and effort.
• Purveyors of Lean Sigma training often just focus on the simpler and more lucrative mass training of staff, instead of the critical but more difficult in-depth leadership training and guidance.
• There is a misconception around just how many change resources are required to make the difference that is being sought (“All we need is one Black Belt and off we go”).
• Change is difficult in the best of cases, but it has been too easy to say, “We’re different from other industries, so it won’t work here.”
• Key stakeholders take the stance that because of its industrial roots, Lean Sigma doesn’t apply to healthcare; this drives a desire to blindly tailor and diminish the approach without first understanding the full context and facets.
• Healthcare is an industry that thrives on quick solutions. The desire to take shortcuts brings about a dumbing down of sophisticated approaches to the point that they are no better than existing methods, which is then followed by asking the bizarre question, “Why is this any different?”
• Leaders and managers are scared of airing dirty laundry in the more open environment of a Lean Sigma culture.
And last, but arguably most important,
• There is often a firmly held belief that the route to improvement in healthcare is through its people, not its processes, and hence the broken, disconnected, or disjointed processes are never addressed.
Many of these arguments relate to healthcare being positioned as different from other industries. Typical phrases are “We’re not a factory or an assembly line” or just simply “We’re different; that won’t work here.” It is correct to state that healthcare is different from any other industry, but to be frank, it’s different in all the same ways. Hospitals, health systems, and their staff
• Interact with customers (patients and physicians)
• Use established processes to perform their work (clinical guidelines, best practices, etc.)
• Are supplied with “stuff” (materials, equipment, and supplies)
• Deliver value in the form of services (assessments, treatments, etc.) and goods (implants, bandages, etc.)
• Invoice customers for the value provided to them
• Collect monetary return for services rendered
• Rely on financial performance as well as quality and associated customer satisfaction
Viewing healthcare in this context, Lean Sigma is absolutely transferable to and wholly applicable in healthcare.2
2. For concrete examples and success stories, see Chapter 4.
Who This Book Is For
This is a guide for everyone in the healthcare industry (from clinics to hospitals to health systems), from the sharp-end, patient-facing staff to the senior executives. It should be applicable to physicians, nurses, staff, executives, administrators, and quality and compliance groups alike. It is meant for those seeking to understand how to bring an effective Lean Sigma program to their organization, or to better their current program.
This is not a guide for an untrained project leader—don’t expect to read this and be able to lead a Lean Sigma project (this book will just make you dangerous). However, for the trained Belt, Chapter 3 may open your eyes to a new way of thinking about your work.
Neither is this book intended to teach the reader how to use the tools associated with Lean Sigma. There are other texts that provide that instruction, including the author’s.3 This book will explore the infrastructure necessary and sequencing of Lean Sigma projects and why they are important, not tool execution. This text and books on tool instruction are useful companions to each other.
3. Ian Wedgwood, Lean Sigma: A Practitioner’s Guide (Prentice Hall, 2006).
The conclusions in this book are based on the author’s two decades of experience in deploying Lean Sigma, leading projects, and consulting across multiple industries, with more than a decade of that time in healthcare. None of this is theory or conjecture, so it should appeal to the practitioner—the practical, and the pragmatic alike.
How to Use the Book
The book is meant to be read end to end. The goal is to broaden the readers’ thinking and expose them to facets of change that are not normally considered. It is probably unwise to skip sections. There is much misunderstanding of Lean Sigma in healthcare, which is probably in part a result of making assumptions to fill gaps in the fabric of understanding. Read the whole text to understand the framework—don’t just pick and choose.
This book centers on the leadership aspects of a change program and is structured as follows:
• Chapter 1 highlights the failure points in the existing change methods and how they contrive to prevent healthcare performance from truly improving.
• Chapter 2 explains the structured change approach of Lean Sigma at a program level, across projects: how it fits with strategy, operations, and other initiatives.
• Chapter 3 gives a high-level overview within a project of the roadmap and tools—that is, how to tackle an individual process and elevate its performance level.
• Chapter 4 gives case study examples of the application of Lean Sigma to different areas in various healthcare organizations: the focus, approaches, achievements, and leadership learning.
• Chapter 5 explains the various stages of maturity of a program and how best to start to bring this to your organization.
The book can be used as a tool to support commencement or reinvigoration of a deployment of Lean Sigma across an organization, so once you’ve read it
• Hand it to (other) senior executive team members.
• Distribute it to all leaders and managers.
• Use it as a communication tool: “Read this, then we’ll talk.”
Acknowledgments
I’d like to acknowledge the host of healthcare leaders across dozens of client organizations who helped shape the understanding and viewpoints shared in this book.
A special thank you to Jim Bickel, CEO, and his team at Columbus Regional Health (CRH), and in particular to Marlene Weatherwax, CFO, and Doug Sabotin, Director of Lean Sigma. I’d also like to thank the project and department leaders who provided the case examples in Chapter 4, including Carolyn O’Neal, Sharon Chandler, Natalie Thieret, and Bill Algee at CRH; Nikki Tumey and Bob Siegmann at Centerstone Behavioral Health; Kevin Knoll at Floyd Memorial Health; and Debbie Hudson at Norton Health.
Thanks also to Dr. Richard Allen for his supporting insight and work to review the manuscript, despite my congenital aversion to commas.
As always, I just don’t have enough words to express my appreciation to my wife, Veronica, and my sons, Christian and Sean, who encourage and support me in everything I do.
Finally, to all the performance improvement and quality groups working tirelessly every day to make healthcare safer for us all: to you we are all indebted.