3.1 A Brief Introduction

Anyone who works in the healthcare field has probably heard about continuous improvement (CI) methods. Readers might also be familiar with specific CI philosophies such as Lean, Six Sigma, or Lean Six Sigma (which combines elements of the two aforementioned systems). To quote an oft-used cliché, “These topics are hot right now.” Numerous books, articles, and training guides offer to help healthcare administrators incorporate CI processes—of one sort or another—into their workplace routines. Many healthcare organizations will pay a premium to employees who hold certifications in Lean and Six Sigma. Some of these companies will also spend sizeable amounts of money to bring in CI experts to educate their workers on the newest quality improvement (QI) techniques. As important, a large number of health services firms, especially hospitals, have either incorporated or are in the process of integrating CI practices into their corporate infrastructures.

While a growing percentage of healthcare employees are intimately familiar with the ins and outs of Lean, Six Sigma, and other CI methods, a large number of individuals who work in this field probably know very little about them. Many of these people, especially ones who are engaged in non-clinical areas, might not yet have the incentive to learn about CI processes because they work for companies that possess a cohort of experts who handle all of the CI-related tasks. Others are likely affiliated with organizations that have only implemented CI techniques in certain departments or service lines. Some healthcare staff may work for firms that have not yet adopted CI processes, for one reason or another. In many cases, they would like to learn more about systems like Lean and Six Sigma, but they do not have the requisite time or money to take the certification classes. Alternatively, these men and women might refrain from studying these methods because they do not believe that their departments have the resources to implement the data-intensive, team-based approaches, which are the hallmark of many CI-related processes such as Lean and Six Sigma (Sessoms, 2016; Sherman, 2014).

I have written this narrative with an eye to the healthcare administrators (or future leaders) who have only a limited knowledge of CI processes, in general, and Lean or Six Sigma techniques, in particular. I hope to provide readers with a brief overview of these philosophies. As such, I focus almost exclusively on core concepts and “big picture” ideas, while avoiding more nuanced in-depth discussions of the topics. I begin by describing some of the key elements that underlie any type of CI process. Next, I focus my attention on Lean and Six Sigma—two CI systems that have garnered a lot of attention in the healthcare field in the past few years. Finally, I denote some of the potential problems that resource-challenged firms or departments might face in adopting and using CI-focused methods of any type.

My goal in this chapter is twofold. On the one hand, I have developed this primer for individuals who know little about CI processes such as Lean or Six Sigma but who nonetheless have to incorporate some of these techniques into their particular department’s operational structures. These readers can use the information from this chapter to help them understand which CI-related strategies best meet their specific office’s needs. At the same time, healthcare supervisors who want to learn the basics about CI, Lean, and Six Sigma (but who do not immediately need to implement these strategies) will hopefully be able to glean some valuable information from perusing this narrative.

3.2 CI Defined

Any supervisor, in healthcare or another field, who is interested in creating an office culture that supports CI (or, as it is often called in healthcare, continuous quality improvement [CQI]) initiatives must have at least a basic understanding of its concepts. People who adhere to CI dogmas believe that a corporation’s systems and practices rarely work flawlessly, which leads to wasted resources and imperfect products and services. They look for ways to improve these processes to make them more efficient and effective. CI practitioners often use systematic, empirical, and/or quantitative methods to identify and ameliorate flaws in work processes (Linich & Bergstrom, 2014, pp. 6, 8; Spath, 2009, pp. 14–19; Williams, Savage, & Stambaugh, 2012, pp. 122–123). However, they can sometimes utilize ad hoc or informal methods to achieve their improvement-focused objectives (Murray, 2010, locs. 1811 and 1818; Spath, 2009, p. 12).

Importantly, CI practitioners view all improvement projects as works in progress. For one thing, they will usually seek to incrementally enhance the performance of a service, process, or product instead of trying to fix everything at one time (Jha, Noori, & Michela, 1996, pp. 27–28). Even if or when the QI team (or individual) feels that they cannot further improve a process, the group will still routinely monitor the system to ensure it remains problem-free (Chapman, 2007, pp. 40–41). CI experts also adhere to the corollary condition that the improved practices must “meet or exceed customer [or other stakeholder-related] expectations” (Williams, Savage, & Stambaugh, 2012, p. 122). Proponents of CI do not stop once they have succeeded in solving a problem. Instead, they continually look for new processes that they can improve (Duggan, 2016; Spath, 2009, p. 107). In other words, individuals who follow CI guidelines will continuously seek to improve the projects at hand and, at the same time, try to identify other issues that they can tackle in the future.

3.3 The Differences between CI and Organizational Churn

Although healthcare companies that are committed to CI continuously seek to improve processes, they do not constantly want to change their workers’ routines or incessantly tinker with employees’ day-to-day service and product-related practices. Executives and office-level leaders who adjust their workplace’s methods because they “like changing things up” are not using CI-based philosophies. Instead, they are engaging in organizational churn, which involves making changes to office-based protocols without delineating why these alterations are necessary or aligning them with QI strategies. Individuals who take these actions rarely help their employees to become more efficient or effective. These administrators’ choices might actually hurt their particular firm’s quality and productivity aims because their decisions leave staffconfused, irritated, and burnt out (Black, 2007, p. 25; Van Wyk, 2014).

In my experience, this phenomenon correlates with poor leadership at the organizational or departmental levels. In these instances, management champions one initiative after another, but it does not see many (or sometimes any) of these projects through to the end. Executives or administrators will foist new routines or regulations onto their employees with gusto, and they will happily oversee an initial push to get their workers to adopt these changes. However, the leaders will quickly lose interest in these projects; they will often “take their feet off the pedal” just as frontline staff are getting used to the adjustments.

At one point in my career, I worked in the aforementioned type of environment. Speaking from experience, I can attest to the damage that an organization can inflict upon itself when it creates this type of project churn. The firm’s inability to follow through on initiatives hurt employee morale. Subordinates grew frustrated by the lack of clear guidance from upper management. In many cases, they did not know what the actual steps were for a given process; they simply “winged it” and hoped for the best. Perhaps most deleterious of all, the staff lost faith in their leaders; these individuals felt that they could not trust managers and executives who were loath to commit to projects or protocols. Predictably, the company’s employees left in droves. The ones who stayed often did not give 100 percent, and they sometimes intentionally flaunted the rules (when they actually knew what the regulations were).

Though a reader might be able to think of some exceptions to the rule (e.g., a start-up firm with only a few employees might be justified in tinkering with processes until it “gets things right”), a healthcare corporation that fosters constant change is not practicing CI (Van Wyk, 2014). By contrast, a CI-friendly organization will carefully plan out and follow through on proposed improvements. As part of this process, the company will, among other things, work to properly educate relevant members of its workforce to handle these adjustments (Sollecito & Johnson, 2013a, p. 3).

3.4 Key Steps in the CI Process

Healthcare administrators who are interested in CI can choose from among a number of different systems. Each of these methodologies will utilize its own set of formulas and tools. However, any individual or group that is taking part in a structured CI project, regardless of which techniques they use, will almost always perform some of the same basic steps (though perhaps not in the precise order listed below), including the following:

• Identify the Problem: During this initial stage, a healthcare company’s CI staff would attempt to identify the problem they would like to address and ascertain its scope (Louisiana Department of Children and Family Services, 2016). Sometimes, healthcare administrators and employees may easily be able to describe the issue that they want to solve. However, in other instances, CI improvement personnel might need to perform several actions in order to identify the problem. In either case, an organization must correctly delineate the impediment before it can posit solutions to this problem.
• Come Up with a Plan of Action: During this stage, the people involved in a specific CI initiative would “define their improvement goal” (Spath, 2009, p. 106). They would also create an action plan for achieving this aim. As a part of this process, the individuals would try to figure out what resources they would need in order to fulfill their objectives. Additionally, the staff would designate a timetable to complete the QI process and perform any other related tasks (Spath, 2009, pp. 156–161).
• Analyze the Existing Practice or Process: Put simply, the individuals who are involved in the CI initiative would delineate the key personnel, features, tasks, and steps that comprise the process that they seek to improve upon. During this analysis, the CI staffwould look for flaws, bottlenecks, or other problems with the targeted practice or system (Spath, 2009, pp. 106–107). The staff members could use a variety of methods to accomplish these assays. I will touch on some of these techniques later in this chapter.
• Design and Execute Improvements: During this stage, the employees who are working on the CI improvement project would come up with possible solutions to the problem and then implement these strategies (Spath, 2009, pp. 106–107).
• Evaluate and Re-evaluate: If an organization’s staff members are committed to CI, they will not end the QI initiative once they have implemented the proposed changes. Instead, the individuals will use a variety of metrics and techniques to gauge their success in implementing the solutions. These employees should perform the measurements more than once over a specified period of time. The healthcare firm can use this feedback to help it (a) design new solutions if the first ones proved to be unsuccessful, (b) find ways to further improve the process, or (c) routinely monitor the situation to espy any reoccurrences of the old problems or the onset of new concerns (Kelly, Johnson, & Sollecito, 2013, pp. 103–105; Solberg, 2013, p. 404).

3.5 CI-Focused Corporate Cultures: Reviewing the Past, Monitoring the Present, and Controlling the Future

From what I have seen, healthcare organizations that want to take CI seriously need to review their employees’ past actions, monitor present processes, and try to foresee what the future will bring. Healthcare companies can achieve these goals by conducting retrospective analyses, by observing key services in real time, and by performing prospective studies in order to identify and ameliorate potential upcoming process-related problems. Below, I will provide a brief overview of each type of assessment.

3.6 Reasons for Adopting CI

Healthcare organizations can potentially realize a number of benefits if they possess a culture that supports CI methodologies. Some of these advantages include:

• Improving the Quality of Care: Hospitals and other clinically focused providers can use CI techniques to aid them in reducing medical errors. These organizations’ employees also might be able to utilize CI methods to help them provide more effective care to patients and other customers (Health Resources and Services Administration [HRSA], 2011, p. 6). Health services providers can use Lean, Six Sigma, or similar systems to accomplish other patient safety or healthcare quality-related goals, including decreasing wait times and increasing access to services (Richins & Holmes, 1998, pp. 281–285; Williams & Fallone, 2008, p. 517).
• Reducing Expenses: Healthcare providers can use CI techniques to help them become more efficient by streamlining their processes and practices, as well as by identifying other ways to remove “waste.” In some instances, these organizations can use the cost savings to help them fund QI initiatives. At other times, they can bank the money (HRSA, 2011; Sollecito & Johnson, 2013a, pp. 6–7).
• Increasing Patient/Customer Contentment: Healthcare corporations can use CI-based techniques to help them create client-centered cultures that maintain high customer satisfaction rates. These organizations can utilize CI to help them identify and fix problems that are frustrating or angering their patients and customers (e.g., wait times, parking issues, etc.). They might also see an uptick in client satisfaction if they are able to improve the quality of their services (HRSA, 2011; Sawyer, 2016; Sollecito & Johnson, 2013a, pp. 10–11). In a broader sense, healthcare firms that put the customer first should generally score better on patient satisfaction surveys (Rickert, 2014). As I will discuss or imply in various places in this book, these entities can incorporate CI-focused methods as part of their drive to create and maintain these patient-centered cultures. Many researchers agree with me on this point (Sawyer, 2016).
• Satisfying Employees: As I will discuss at later points in this book, a healthcare organization’s workers, on the whole, usually have to be relatively content with their office environment in order to participate fully in a CI-focused culture. At the same time, companies can often improve employee morale at their facilities by utilizing CI (Radawski, 1999, pp. 12, 16; Shortell, Levin, O’Brien, & Hughes, 1995, p. 7). One could posit any number of potential reasons for the correlation. Regardless, this is an important benefit to adopting CI practices that administrators probably do not think about (but should consider).
• Enhancing Relationships with Other Key Stakeholders: A health-care organization can also leverage any improvements in the previously mentioned categories to aid it in winning over other key stakeholders (HRSA, 2011).
• Meeting Accreditation or Regulatory Requirements: Many U.S. healthcare organizations have to perform a range of CQI-type activities in order to meet accreditation or regulatory guidelines (Sollecito & Johnson, 2013a, pp. 6–7; Sollecito & Johnson, 2013b, p. 61). The groups are not likely to remove these requirements in the near future. Instead, they will probably put forth additional mandates that lead “to [a] greater diffusion of CQI” in healthcare (Sollecito & Johnson, 2013b, p. 61).

3.7 CI Immersion: The Three-Level Perspective

Assuming it only has one facility, if a healthcare company’s culture is fully supportive of CI, the staff will be capable of undertaking CQI initiatives at the organizational, departmental, and individual levels.

• Organizational-Level CI Initiatives: In these instances, the staff at a healthcare company will work on an improvement project that involves more than one department. Many experts argue that the typical health-care firm should focus the majority of its resources on these types of initiatives. They state that, given the interconnected nature of the current workplace, it is difficult for employees in any one unit to perform their jobs without directly or indirectly impacting a number of other areas within the company. Hence, it makes sense for staff from several departments to work together to solve problems that affect them all in some way or another (Linich & Bergstrom, 2014, p. 9; Sollecito & Johnson, 2013b, p. 61; Thompson, Buchbinder, & Shanks, 2012, p. 9).
• Departmental-Level CI Initiatives: Healthcare administrators and staff can use CI techniques to improve work-related processes in their particular departments. In these cases, the employees will not involve people from other offices in this work, though given the interconnected nature of the modern healthcare facility, their department-level initiatives might impact other areas of the company.
• Individual-Level CI Initiatives: Most of the literature that I have read devotes little attention to CI initiatives that are conducted by individuals in an effort to perform their jobs more efficiently or effectively. The lacuna might be due to the fact that employees, when trying to improve their own work routines, do not always follow the formal guidelines or structured methods that are part and parcel of most CI systems. However, in my experience, any healthcare corporation that wants to commit itself to CI methodologies must possess a workforce that, on the whole, is self-confident, engaged, and at least partially autonomous (more on this topic later). Many of these staff members, through trial and error or other techniques, will actively attempt to become better at what they do. Further, they sometimes will seek to enhance their work-related skills and abilities without any prodding from management. A CI-supportive culture encourages these types of employee behaviors (Ahmed, Loh, & Zairi, 1999, pp. s426–s427).

3.8 Lean Six Sigma

In the first part of this chapter, I focused on CI in general. There are many different systems that espouse some or all of the methods and goals listed in the previous sections. Each of these philosophies comes with its own set of terminologies, techniques, and strategies. I will now focus on one such methodology, Lean Six Sigma, which is utilized in some form or another by a sizeable number of hospitals and other healthcare organizations.

In this book, I might differ from other scholars when I use the term Lean Six Sigma. Here, I am simply referring to a system that incorporates elements from both Lean and Six Sigma. I feel that, given the diverse nature of the healthcare field, it is up to each organization to decide which aspects of these two process management theories it will utilize. Throughout this chapter, I will attempt, when possible, to delineate the practices that fall in the Lean category and the ones that belong to Six Sigma. By taking this approach, I hope to provide readers with a primer on both methods and leave them in a better position to determine which pieces of each philosophy they want to use in their office environments.

Many of the CI-related books that I have read tend to make the conversation on Lean and Six Sigma more complicated than it has to be. As a result, lay-people who do not know anything about these methods, and even individuals who are somewhat acquainted with these systems, struggle to understand the basic concepts. With that fact in mind, I have, when possible, eliminated the jargon and foreign words. I try to provide readers with some of the key Lean and Six Sigma basics in a format that is both clear and concise.

3.9 The Key Philosophical and Methodological Differences between Lean and Six Sigma

Lean Six Sigma is derived from two distinct CI systems—Lean and Six Sigma. Although they have many things in common, the two philosophies contrast with each other in several ways. Perhaps most importantly, proponents of Lean and Six Sigma differ regarding their end goals. People who subscribe to the former method focus on improving production times, enhancing service flows, and reducing costs by minimizing “waste.” The term “waste,” in this instance, can be defined as anything that does not add value to the service or product and includes “wasted time, effort, and material” (Summers, 2007, p. 348). Adherents of Six Sigma, although attentive to “waste,” focus most of their attention on improving quality or value for internal and external clients by reducing “process variation” (Summers, 2007, p. 348). They seek to accomplish this task by finding and eliminating or at least ameliorating the root causes of the errors or defects (McKenzie, 2009).

One other key way in which Lean differs from Six Sigma is in the tools that their proponents employ to collect, analyze, and disseminate information. Practitioners of Lean strategies place more emphasis on the use of visual-based guides. A team that utilizes Lean methods would rely heavily on observations, interviews with staff, and flowcharts to map out a work-related process or service and identify wasteful steps or procedures. The group would also likely use visual tools to help it construct solutions to these problems as well as to disseminate its findings to key stakeholders (Pojasek, 2003, pp. 86–88). At the same time, executives and administrators who adhere to Lean methodologies would employ graphical aids (e.g., dashboards) to help employees track their progress towards meeting preassigned goals and to aid these people in locating workflow-related issues (Bartholomew & Hamel, 2014).

Six Sigma practitioners might also sometimes use visual aids such as fish-bone diagrams; however, differing from their Lean peers, the former group places a heavier emphasis on collecting quantitative data. People who rely solely on Six Sigma will then often use statistical methods to help them translate this data into meaningful information. As such, they will likely focus on developing viable collection methods, creating useful metrics, and utilizing proper statistical techniques in an effort to identify the root causes of the identified issues. They will probably also employ statistics to help them create solutions to these problems and to ensure that their improvements operate as expected (Desai, 2013, p. 298). Even when advocates of Six Sigma forego some of these analyses, they will still tend to take a more systematic view of things than their Lean counterparts (Pojasek, 2003, p. 91).

3.10 It Makes Sense for Healthcare Organizations to Utilize Both Lean and Six Sigma

In my experience, healthcare organizations, in both clinical and non-clinical fields, can potentially achieve the best results by utilizing some combination of Lean and Six Sigma. On the one hand, these companies can use Lean techniques to help them achieve goals such as decreasing patient wait times in clinics and improving the flow of customer billing information as it migrates through the various stages of the revenue cycle. At the same time, the institutions can employ Six Sigma methods to help them reduce potentially harmful variations in patient care processes and to identify the root causes of customer satisfaction–related problems. In the proceeding section, I will provide an example that I hope will help to drive home this argument.

3.11 A Case in Point: The Emergency Room Staff Become More Efficient and Effective

After they review this fictional case study, I think readers will see how a health-care organization can utilize both Lean and Six Sigma in clinical settings. In this scenario, the employees of an emergency department (ED) want to find ways to reduce customer throughput times and enhance patient care. The staff members believe that by improving these metrics, they will reduce costs, increase customer satisfaction scores, and achieve better patient outcomes (Amirault, 2012). Working together as a team, they use Lean inspired flowcharts and value stream maps (VSMs) to visualize the patient’s path through the ED from entry to discharge and identify any problems in this process that they can eliminate or at least ameliorate. At the same time, the ED’s workers use Six Sigma–inspired statistical control charts to help them spot any variations in practices or procedures that might negatively impact patient care at their facility. Finally, they use various Six Sigma–inspired techniques to help them determine the root causes of sentinel events.^* By taking these actions, the ED’s employees, over the course of several months, are able to identify and fix key problems in their patient throughput protocols and in their care processes.

3.12 Delving a Little Deeper into Lean’s Key Focus: Streamlining Work Processes by Eliminating Waste

As I noted earlier in the chapter, organizations use Lean techniques to help them make their workflows, handoffs, and service delivery systems more efficient. In the ideal healthcare scenario (which is never possible), employees would work together to ensure that both clinical and non-clinical processes run as smoothly as humanly possible. Managers and other staff who ascribe to Lean philosophies try to get as close to this aim as is feasible by eliminating “waste,” which might include:

• Defects or Errors in Products or Processes: In these instances, employees or machines make mistakes that slow down the specific workflow processes. The inefficiencies arise because staff members have to “waste” time correcting the errors or fixing the defective systems (Graban, 2012, p. 38).
• The Underuse or Misuse of Employee Capabilities: In these instances, healthcare organizations are hampering productivity, efficiency, or patient care by underutilizing or misusing an employee’s talents (Graban, 2012, p. 38). Think of it like pounding a nail into a piece of wood with a screwdriver. One will eventually get the nail into the wood; however, he or she could have performed the job faster with a hammer.
• Overproduction: Staff members create this type of “waste” when they “[do] more than what is needed by the customer or [provide services] sooner than needed” (Graban, 2012, p. 38). In an office environment, overproduction leads to unnecessary costs and delays. It sometimes also results in products or services that are of poor quality. For example, if a doctor performs unnecessary tests or surgeries (overproduction), he or she would not only be wasting money but might also be endangering the patient’s health (Brownlee, Saini, & Cassel, 2014).
• Transportation-Related Issues: When Lean advocates talk about this type of waste, they are referring to the inefficient transportation or delivery of products and services (Graban, 2012, p. 38). For instance, a certified nursing assistant (CNA) would be wasting time if he or she had to constantly travel up and down a flight of stairs to pick up residents’ medicines and supplies, instead of having all of the necessary materials at hand (or somewhere close by).
• Wait Times: This term denotes bottlenecks in the workflow processes, which result in employees sitting idly by until they receive more materials or deliverables from upstream (Graban, 2012, p. 38). When healthcare providers talk about this type of waste, they might also be referring to issues related to patient wait times.
• Excess Inventory and the Related Costs of Storing and Moving these Supplies or Items: (Graban, 2012, p. 38) This is an obvious one that all readers have probably had to deal with at one point or another.
• Unnecessary Employee-Related Motions: This type of waste refers to instances in which workers—due to ergonomic or layout issues—have to input more keystrokes than necessary, move further than needed around the office or building, and so forth. In my experience, almost every administrator, if he or she looks hard enough, can spot instances of this type of waste in his or her department (Graban, 2012, p. 38).
• Overprocessing: “Doing what is not valued by the customer” or performing tasks that are “not aligned with patient needs” (Graban, 2012, p. 38).

3.13 Using the Five S’s as a Means to Understand Lean Principles

Many of the books and training guides on either Lean or Six Sigma will consume hundreds of pages of text. Given that fact, I can only hope to convey a few of their key principles and techniques here. I have chosen to describe one core process strategy for each of these two systems. I will start out by discussing the Five S’s, which Lean practitioners use to help them keep their service lines and workflow chains running as efficiently and effectively as possible. I will then briefly describe some of the charts and diagrams that Lean proponents might employ to help them identify and solve process-related issues. Later in the chapter, I will describe DMAIC, which is a cornerstone of Six Sigma. I will then delineate a few of the important tools that Six Sigma practitioners might use. Throughout this process, I not only try to provide readers with information about these two CI systems but also strive to give them a sense of the philosophies and methodologies that underpin Lean and Six Sigma practices.

Lean practitioners rely on the Five S’s (sometimes written as the 5S or Five S) strategy, or some derivation of it, to help them reduce or remove “waste through improved workplace organization and visual management” (Graban, 2012, p. 89). This system is representative of core Lean methodologies, which stress the use of observation techniques and imagery-based tools such as flowcharts, diagrams, and easy-to-understand labels to eliminate or lessen efficiency-related issues with a product or service line (Graban, 2012, pp. 89–96; Pojasek, 2003, pp. 86–88).

The five S’s in this Lean system refer to the steps in the CI plan. They include:

• Sort: In this step, the Lean-focused administrator works with his or her staffto discard (sell or give away) any equipment or objects that these people rarely, if ever, use. By taking this action, they hope to decrease work-related transaction times; employees will no longer need to sort through “the useless junk” to locate the supplies or machinery that they utilize to complete their daily tasks. At the same time, the department saves money by reducing the overhead costs that come with storing, cleaning, and other wise maintaining unnecessary items (Graban, 2012, pp. 90–91).
• Store: In stage two of the Five S’s process, staff determine which supplies or devices they utilize the most often. These people also pinpoint in which locations they most frequently make use of these things. The employees then place these items nearest to “the point[s] of use” (Graban, 2012, p. 91). In this way, the workers can ensure that they waste as little time as possible when they need to find and utilize these components (Graban, 2012, pp. 91–92).
• Shine: Employees who adhere to this step strive to keep their workplaces neat and tidy (Graban, 2012, pp. 92–93).

• Standardize: A Lean-focused organization wants to ensure that, when possible, physical objects are stored in the same area all of the time. If a staff member uses a tool or device, he or she has to make sure to put it back in the same spot. Additionally, if an employee borrows an item (or uses the last of a supply type) that individual will use a predetermined marker or other reference notation to alert colleagues. In this way, workers always know where the items are (or should be); therefore, they should rarely need to waste time and effort in tracking these things down. A healthcare administrator who follows these principles also wants to make sure that his or her department uses the same markings for each type of object, thereby allowing workers to quickly identify an item and discern its purpose (Graban, 2012, pp. 93–94).

  In a modern healthcare facility, many employees, especially ones who labor in non-clinical areas, spend the majority of their time creating, sending, receiving, and altering digital-based information. Some of these people might not even need to utilize any physical materials at all apart from a chair, a table, and a computer terminal. An office-level healthcare leader who manages these types of individuals should seek to standardize not only the physical workplace but the digital one as well. For example, the administrator and his or her subordinates can seek to normalize screen layouts, digital forms, and other online objects. In taking these actions, the supervisor can improve employee-related workflows.

• Sustain: office-level healthcare leaders and their employees should period ically assess any implemented solutions in order to make sure that these changes are working correctly (Graban, 2012, p. 96).

In reviewing the Five S’s method, one can see how Lean practitioners rely on the system’s core values to help them develop improvement-related tools and strategies. These beliefs include the yearning to eliminate waste, the reliance on visual aids, and the desire to streamline processes.

3.14 Key Tools in the Lean Arsenal

Lean practitioners can employ a number of different tools to help them improve workflow and other processes at their respective institutions. Those people who are averse to mathematics and statistics will breathe a sigh of relief to learn that they do not need to possess a deep background in these quantitative disciplines in order to develop, apply, and understand most of these diagrams and charts. In this section, I will discuss a few of the more prominent Lean-related items. One caveat, Lean advocates are not necessarily the only people who utilize these tools. Individuals who adhere to other CI methodologies might also make use of them. Nonetheless, the charts and diagrams that I will highlight in the proceeding narrative are integral elements of Lean strategies.

3.14.3 Creating Deployment Flowcharts in Order to Identify Process-Related Bottlenecks and Waste

Improvement-minded administrators can utilize deployment flowcharts to better understand the steps in a process as well as to discern “which person or group is involved in each step” (RFF Electronics, 2017). By mapping employees and/or machines to the steps they handle, a QI team can also identify the places in which the handoffs (from one staff member or group to another) occur. This is

Figure 3.1 An improvement team has a lot of leeway with regard to creating a SIPOC diagram. Additionally, the group members do not need to posit a professional-level map. They only need to make sure that each teammate can understand all of the elements and connections in the chart. For instance, one can clearly discern the key suppliers, inputs, outputs, and customers in the above example. At the same time, anyone who works in claims will understand the process, even though the 5^th step is not spelled out (the arrows at the end of the process indicate where the claims are sent).

Figure 3.2 This spaghetti diagram depicts the movements of a person who works in the Commercial Insurance Department. This individual is handling a complex claim for specialized durable medical equipment. After the employee has completed the steps that are necessary to file the patient’s claim with an insurance company, he goes to the vending machine area to get a drink and snack. Many office-level healthcare workers will perform this type of routine a number of times during the typical workday. Readers will notice that I have drawn the movement lines in freehand. The manager or staff member who creates the spaghetti diagram does not have to produce a perfectly designed product; he or she just has to ensure that key stakeholders can clearly see the mobility patterns.

Figure 3.3 This deployment flowchart captures some of the key steps in the processing of a claim for a durable medical equipment company. The graphic follows the process from the point of sale to claim submission. The dotted lines represent optional steps in the process (e.g., the patient forms might already be on file).

important because the areas where a process changes hands are often the places where key systemic problems occur (RFF Electronics, 2017).

Healthcare staff who are interested in creating this type of flowchart would first place the relevant employees, groups, or machines (assuming these pieces of equipment possess some autonomous functions) in header format at the top of the graphic. They will then create columns between each group. Next, the employees will add the stages in the process, using different symbols for each of the key types of steps (Morgan & Brenig-Jones, 2012, pp. 80–82; RFF Electronics, 2017). The deployment flowchart’s creators can choose any symbols to represent the different points; however, they must make sure that everyone in the office understands the meaning of these symbols (most companies use these guidelines: ovals = begin and end points, squares or rectangles = steps in the process, and triangles refer to decision points) (Morgan & Brenig-Jones, 2012, p. 79). Finally, the staffmembers want to draw lines connecting each step in the process (RFF Electronics, 2017). The individuals who are crafting this graphic can include any additional information that they feel is warranted. Figure 3.3 denotes a simple deployment flowchart.

3.14.4 The Value Stream Map: A Lean Staple

Healthcare administrators can use VSMs in lieu of deployment flowcharts or to supplement these graphics. In either case, the VSM contains elements of both SIPOC diagrams and deployment flowcharts (as well as aspects of other visual-based mapping processes); however, the VSM usually possesses more information than either of these two types of maps (Morgan & Brenig-Jones, 2012, p. 84). A VSM will include a detailed listing of the employee and/or machine-related tasks in a process and will progress from an agreed-upon start point to an end point. The map will also contain lines and arrows linking the tasks together in chronological order. Additionally, the VSM will denote points in which work or inventory is held in queue between tasks. Finally, the VSM will denote information on waiting times (time spent in queue between tasks), unit completion times (how long it takes an employee or team to complete an individual job), and cycle times (which combine unit times and wait times) (Graban, 2012, p. 50; Morgan & Brenig-Jones, 2012, pp. 84–88). The individuals who create these graphics can choose to use any symbols they want to delineate the various types of actions; however, staff in charge of drawing these maps typically use a triangle to indicate work that is waiting in queue. They will further designate the type of item in this column—“i” for inventory or “q” for people (Morgan & Brenig-Jones, 2012, p. 84).

Figure 3.4 This is a portion of a value stream map (VSM) that assays a healthcare organization’s insurance billing process. The full VSM would include all of the steps in the system, running the gamut from order entry to claims submission (to the insurance company).

Lean practitioners in healthcare and other industries use VSMs to help them identify areas of waste. One way in which administrators and subordinates can achieve this goal is in utilizing the map to help them espy any redundant or unnecessary steps in a process (Morgan & Brenig-Jones, 2012, pp. 87–92). For instance, a QI team might notice that the patient-billing staff is sending out three letters before calling debtors, when these individuals could achieve better results (and cut out a step) if they tried to contact the customer a few days after mailing the second dunning notice. Improvement-minded supervisors and employees can also use VSMs to ascertain waiting, unit, or cycle times that seem to be unusually long. They can then target these areas for closer inspection in an effort to determine the primary causes of these delays. Additionally, office-level healthcare leaders and other workers can employ VSMs to help them pinpoint areas that are prone to bottlenecks. They can use this information to help them fine-tune their training programs (Morgan & Brenig-Jones, 2012, pp. 87–92). In Figure 3.4, I have posited an example of a value stream map so that readers can see what one of these graphics looks like.

3.15 The DMAIC: Supporting Six Sigma’s Goals of Improving Performance and Providing Value to Stakeholders

When healthcare administrators and staff choose to utilize a Six Sigma strategy to identify and fix problems in their services, processes, or products, they often use DMAIC. This acronym stands for define, measure, analyze, improve, and control. Since the DMAIC method is integral to Six Sigma, it behooves me to include it in this section. At the same time, one can gain insight into Six Sigma’s core methodologies by learning about DMAIC. These philosophies include its belief in systemic analysis, the reliance on quantitative data and statistical methods, the focus on eliminating variation, and the desire to understand the root causes of problems (Summers, 2007, pp. 98–99).

I do not have the space in this section to provide readers with a detailed analysis of the DMAIC process. Instead, I will quickly try to summarize each of the key stages that comprise this Six Sigma strategy. I think this will suffice to serve as a primer on the topic.

As I noted earlier in this section, DMAIC stands for define, measure, analyze, improve, and control. A Six Sigma–focused leadership team will follow a series of guidelines that are related to each of these keywords. They will usually proceed in a systematic, orderly way—starting with the D(efine) and moving in chronological fashion until they reach the C(ontrol). Below, I posit a very brief analysis of these steps.

• Define: Selected healthcare staff or other stakeholders craft a QI-related document that identifies the problem to be solved, delineates the goals (what the improvement team will try to accomplish), and creates guidelines for the individuals working on the QI project to follow. After the developers of the project complete this step, they will create the QI team. This group should be composed of relevant stakeholders (e.g., include employees who work in the areas under analysis) (Summers, 2007, p. 99).
• Measure: In this stage of the DMAIC, the QI team seeks to “gather information about the existing process” (Summers, 2007, p. 99). During this phase, the group collects pertinent data. They then use statistics and other techniques to transform this data into meaningful information (Summers, 2007, p. 99).
• Analyze: During this phase of the project, the QI team attempts to ascertain the potential root causes of the “problem they are working on” (Summers, 2007, p. 112). As part of this process, the group seeks to identify cause-and-effect relationships between “the key process input variables and the key process output variables” (Summers, 2007, p. 112).
• Improve: In this step, the QI team comes up with possible solutions to the problem they are trying to tackle. They then attempt to implement these fixes. In taking this action, the group needs to ensure that its remedies are cost effective, address the “root cause[s] of the problem,” demonstrate the potential to “prevent a recurrence of the problem,” and can be implemented in a timely fashion (Summers, 2007, pp. 119–120).
• Control: Once the staff members have implemented the solutions, they should put a plan in place to monitor the improvements. Their goal in doing this is to ensure that (a) the remedies work and (b) that employees or other stakeholders involved in the affected departments adhere to any changed protocols, regulations, or workflow processes (Summers, 2007, p. 122).

3.16 Key Tools in Six Sigma’s Arsenal

Six Sigma teams can utilize a number of different tools and charts to aid them in improving business-related processes. Although these people do employ visual-based aids, they also make use of statistical methods. A reader who peruses Six Sigma–focused graphs and diagrams will note that they tend to rely heavily on root cause analysis (RCA) and cause–effect relationship mapping.

In this section, I discuss a few of the more prominent Six Sigma–related tools. Readers should note that while Six Sigma practitioners rely on these methods, they are not necessarily the only group of people who use them.

3.16.2 The Pareto Chart: A Way to Determine Which Causes Are Most Important

The Pareto chart is named after Vilfredo Pareto, an Italian economist and engineer, who noticed that a small number of families in Italy controlled most of the country’s wealth. When creating these charts, healthcare staff follow the principle that “only a few defect types account for most of a product’s quality problems” (Bowerman, O’Connell, & Murphree, 2009, p. 52). Six Sigma practitioners utilize these diagrams to help them to visually discern the most important process or product-related problems (Summers, 2007, p. 102).

In order to create a Pareto chart, healthcare administrators or staff first count the number of times (the frequency) errors or defects in a product or process occur. They then change the raw scores into percentages. Next, the individuals utilize Microsoft Excel or another program to help them to put these measurements into a bar chart. The diagram lists the problems in decreasing order of frequency, with the most common error or defect on the left side of the chart and the least frequently occurring one on the right side of the graphic. The

Figure 3.5 An improvement team might use this fishbone diagram to help them ascertain the root causes of the high error rates on insurance claims.

workers might also want to include a line, running from left to right, that indicates the cumulative total of the errors, though this step is optional (Bowerman, O’Connell, & Murphree, 2009, pp. 52–53; Summers, 2007, pp. 102–105). Please refer to Figure 3.6 for an example of a Pareto chart.

3.16.3 Managing Variance with Statistical Control Charts

Statistical control charts are a key component of many Six Sigma–inspired improvement schemes. In my experience, healthcare administrators and staff can use these charts to help them identify, in real time, problematic variations in a process or series of routines before these issues cause undue delays in services or harm to patients. To put it another way, QI-focused personnel can employ statistical control charts to help them keep workflows or other processes flowing normally (Summers, 2007, pp. 176–177). At the same time, QI teams can use the graphics to aid them in ascertaining the effectiveness of the solutions that they implement (the “control” portion of the DMAIC). They can accomplish this feat by using statistical control charts to help them assay whether or not their interventions have led to beneficial, medium, or long-term variations in a process (Morgan & Brenig-Jones, 2012, p. 125).

A CI-focused healthcare administrator or employee can choose from a number of different types of statistical control charts, with each one serving a particular purpose. At the same time, almost all of these graphics share a few things in common. Importantly, they all contain a series of points that are part of a larger process. For instance, an ED’s control chart might include the number of people per day who have spent more than 30 minutes in the waiting room; the diagram will consist of one plot point per day and span a number of days (e.g., over a 30-day period). These entries will be presented in run-chart form. A statistical control chart, in addition to possessing these data points, contains a mean (midpoint) line. It also possesses an upper control limit line (UCL), which is three standard deviations above the mean line, and a lower control limit line (LCL), which is three standard deviations below the midpoint line. If a process is behaving normally, all of the points should fall within the space created by the UCL and LCL. Additionally, some of these points will fall below the midpoint and some above. If a point falls outside the UCL or LCL, or “a run of seven or more consecutive points” go up, go down, or fall above or below the mean (midpoint) line, then the process is no longer in control. In these instances, one can usually conclude that a significant defect, error, or other issue might be limiting the system’s efficiency or its effectiveness (Morgan & Brenig-Jones, 2012, pp. 121–129).

Figure 3.6 A Pareto chart denoting the types and quantity of claims-related errors over a three-month period. Anyone viewing this graphic will immediately notice that coding mistakes and missing physician documents account for the largest number of claims-related errors during this span of time.

Sometimes a picture is worth a thousand words. In this instance, I have created two graphical aids to help readers understand how statistical control charts work. In Figure 3.7, the control chart indicates that the process is working as planned. By contrast, in Figure 3.8, the diagram pinpoints key issues in the process.

3.17 Key Principles that Both Lean and Six Sigma Have in Common with Each Other

In the previous sections, I discussed some of the key differences between Lean and Six Sigma. I then highlighted a few of the methods and tools that are part and parcel of each of these two systems. However, it is also worth noting that Lean and Six Sigma share many things in common. In the short space allowed to me here, I want to focus on three of these similarities, including their focus on managing by fact, on keeping things simple when possible, and in requiring workers who are engaged, flexible, and adaptive.

3.17.2 Keep It Simple When Possible

People who subscribe to Lean principles and those who adhere to Six Sigma methodologies strive to keep things as simple as possible. Lean practitioners focus on creating visually descriptive diagrams that all stakeholders can understand. As such, their goal is in adequately describing the process and identifying the key problems without creating a chart or series of graphics that are too

Figure 3.7 This control chart indicates that the number of coding errors per day (over a 15-day period) varies, as expected.

Figure 3.8 Notice that the number of coding errors exceeds the expected variation levels from January 28, 2016, through January 30, 2016. A manager who is perusing the chart would infer that something out of the ordinary is impacting the process, which might be a cause for alarm. Readers will note that this control chart looks a slight bit different from the previous one. That is intentional; one can alter specific aspects of these graphics, as long as they achieve their particular purpose.

complex for management, workers, or other key stakeholders to comprehend. After all, if these groups cannot grasp the problems in a process, they will have a hard time accepting the potential solutions to these issues (Stark, 2016). At the same time, while Six Sigma adherents might rely more on statistics (the very word is terrifying to some people), they also want to keep things as straightforward as is feasible—and for the same reasons as their Lean counterparts (Summers, 2007, pp. 289–291, 329–330).

3.18 The Problems that Leaders at Resource-Challenged Institutions Face in Fully Utilizing Lean or Six Sigma

While some individuals work for well-capitalized healthcare organizations, many people are employed by firms that struggle to stay in business. These companies might not possess the resources to pay for employees to earn Lean or Six Sigma certifications. Additionally, administrators might work for healthcare corporations that do not have the available personnel to undertake full-scale improvement projects (as envisioned by Lean and Six Sigma gurus). Individuals who work for these types of institutions might rightly ask, “What can I gain from reading this book?”

Later in the text, I will provide some helpful CI-related tips that administrators at all types of healthcare organizations can use. At the same time, I will also demonstrate how an office-level healthcare leader at a resource-challenged company might utilize some specific CI-related techniques to help him or her improve employees’ efficiency and effectiveness. Finally, I think that most readers can benefit from perusing my discussions—at key places in this book—on creating healthy workplace cultures and motivating employees.

3.19 One Thing to Keep in Mind When Integrating Lean Six Sigma Ideals (or Any Other CI-Related Processes) into the Workplace: Embrace Technology and Routines but Do Not Stamp Out Creativity and Individuality

As I noted earlier in the chapter, healthcare administrators can potentially utilize CI techniques to help them reduce costs, increase revenues, and improve patient care at their organizations. However, they need to remember that some inefficiencies are good (or at least are necessary). On the one hand, federal, state, local, and accrediting agencies require hospitals and other healthcare providers to perform a number of tasks that are not necessarily cost effective or efficient. Just as important, healthcare is a service-related industry. Many employees spend a good portion of their workdays interacting with patients, residents, or other types of customers. This is true in both clinical and non-clinical spaces. Healthcare supervisors need to remember that, in these instances, their staff might have to do things that are impromptu and/or inefficient in an effort to satisfy their clients’ needs. For example, workers might have to go “off script” to bring a smile to a child’s face or to meet a caregiver’s demands.

At the same time, people are not robots. Most of them want to maintain some control over their work routines and to perform a varied array of tasks throughout the day. In my experience, individuals who work in environments that are bereft of these two traits (i.e., that do not allow them these freedoms) soon become bored and burnt out. In order to combat this issue, I think that healthcare leaders—in all positions and at all levels—should allow their employees some autonomy, even if it reduces these workers’ short-term output levels. I refer to this concept as “structured autonomy,” and I will discuss it in more detail later in the book.

3.20 Summing Things Up and Looking Ahead to Chapter 4—Motivating Employees: Redesigning Organizational Level Processes to Create a Culture of Continuous Improvement

I divided this chapter into three sections. In the first part, I looked at a number of basic elements that are part and parcel of almost any CI process. Next, I delineated some key aspects of two of these CI systems—Lean and Six Sigma. At the same time, I demonstrated why office-level healthcare leaders might want to use these two philosophies in tandem. In the final portion of this chapter, I denoted some problems that resource-challenged institutions may face in trying to implement either Lean or Six Sigma methods. I also suggested that leaders not take CI too far; they should instead embrace some processes or protocols that are inefficient in order to meet certain stakeholder-related goals.

In the next chapter, I highlight some of the key cultural aspects that health-care organizations probably need to possess if they want to successfully integrate CI methods into their workplace routines. As part of this process, I look at ways in which healthcare leaders can use symbolism to help them develop and maintain environments that support CI philosophies. I also posit some commonsense tactics that executives and administrators can use to help them promote CI-friendly office cultures. At the same time, I explain why healthcare leaders want to create corporate environments that foster optimistic employees who embrace technological change.