Lean Six Sigma for healthcare: Improving the health of healthcare processes

As Garbage-In-Garbage-Out, automation of a bad process is still a bad investment that would not reap the expected return. Lean Six Sigma would help hospitals and other healthcare institutions streamline their processes and improve them as deserving candidates for digitisation, analyses Vijaya Sunder M, assistant professor of practice, Indian School of Business (ISB), Hyderabad, India and affiliate faculty, Max Institute of Healthcare Management (MIHM) at ISB

Today, healthcare has emerged as a dynamic force providing higher employment and topline benefits to hospitals globally. Providing quality healthcare services to patients becomes pivotal towards this effect, and hence healthcare quality becomes an essential requirement for hospitals, amidst the competition that pervades the healthcare sector. Research shows why and how healthcare institutions’ primary objective is to provide quality services effectively and efficiently.

With the increasing demand rate, it is evident that India’s current healthcare infrastructure is not adequate to serve. Lack of proper appointment scheduling systems, less efficient test results sharing systems, higher patient turnaround time, longer waiting time, lower occupancy rates, higher discharge times, inadequate staffing, lower medical equipment utilisation, lower patient satisfaction and safety rates, patient room turnover rate, administrative and supply costs are some major challenges faced by healthcare institutions.

Research shows evidence of the successful application of Lean in the healthcare sector due to the transformative benefits that it has delivered to various healthcare organisations. The Lean healthcare systems worldwide witnessed a significant evolution in the past two decades by transforming the processes and the behaviours within the healthcare firms.

For example, Mayo Clinic in the US implemented Lean in the early 2000s and achieved higher customer satisfaction among the cancer patients in their chemotherapy department. Another such example is that of the National Health Service in the UK, where Lean deployment has improved hospital performance and delivered significant cost savings. Subsequently, other healthcare institutions like Virginia Mason Medical Center, Thedacare Inc., Denver Health in the US; Foundation Trust, Royal Sussex County Hospital in the UK; Shouldice Hernia Centre, St. Joseph’s Health Centre in Canada; Flinders Medical Centre, Campbelltown Hospital in Australia, etc., have adopted Lean Thinking. Even in developing economies such as India, Lean implementations have transformed both clinical and non-clinical processes among the hospitals.

While Lean implementation in the healthcare sector has provided some success, it had its share of drawbacks too. First, most of the Lean works in healthcare links to the traditional Toyota Production System and have not included the recent developments in Lean. Second, implementing Lean in hospitals has been a daunting task in many countries, as Lean does not demand a data-driven approach. Third, several studies emphasised that the leading cause for poor patient care in hospitals is the incorrect selection of Lean projects based on hospital management’s intuition.

Further, in many organisations, Lean has been perceived as an ad-hoc activity without considering its systemic implications.  While the Lean literature endorsed several field-based tools like value stream mapping and visual management, it missed recognising other important continuous improvement (CI) tools like process mapping, control charts, root-cause-analysis, etc. Importantly, Lean does not address process variation related issues.

Finally, the criticism that Lean lacks a project management framework to execute projects has been a concern among practitioners. Alongside these, the healthcare sector’s intrinsic challenges like inherent unevenness in healthcare operations, measurement system and quantification challenges, demarking healthcare as a market, defining patient as a customer, have been vague and, in fact, majorly unaddressed.

With the recent development of Lean Six Sigma, a hybrid method that combines the rapidness of Lean and Six Sigma’s robustness, most of these problems get addressed. Our research and practice of applying Lean Six Sigma in various healthcare contexts that include out-patient departments, mobile hospitals, pharmacies, healthcare insurance, diagnostic labs, intensive care, and in-patient admits have convincingly endorsed Lean Six Sigma’s fitness for providing high-quality and low-cost healthcare services.

While Lean Six Sigma was built on Six Sigma’s original Define-Measure-Analyse-Improve-Control (DMAIC), and Define-Measure-Analyse-Design-Verify (DMADV) roadmaps, it is a data-driven, process-oriented continuous improvement approach that focuses on identifying and eliminating process defects, variation, and non-value-adding time to improve healthcare service efficiency and effectiveness. Simultaneously, it helps improve process flow, utilisation, flexibility, and service capability towards delivering greater value to patients and other healthcare beneficiaries.

Recently, we had an opportunity to apply Lean Six Sigma in a multi-specialty hospital in India that offers primary and specialty medical care, and NABH certified. The hospital with more than 1000 beds serves over a million patients annually and 1000 patients per day. It consists of 10 departments for multi-specialty, 40 departments for patient care and administration with 3500 staff members.

As per the hospital archives, the patient satisfaction rate was about 78 per cent in the cardiology department. The turnaround time (an average of 315 minutes, with a standard deviation of 24 minutes) was reported as a major contributor to patient dissatisfaction and identified as an opportunity for process improvement by the department’s management.

Data analysis revealed a poor process capability to deliver services within the set objective of 210 minutes. By applying the Lean Six Sigma toolkit, we were able to identify the root causes of the problem. Lack of scheduling, incomplete patient information, lack of test result alerts, lack of clarity in patients about the hospital layout, workstation downtime, delays from other appointments, and demand fluctuations were a few of the root causes.

Lean Six Sigma tools like Pareto analysis, Control charts, Value Stream Maps, and data analytics were used as part of the project. The integrated mobile alert system, standardising the lab data reporting, revamping the scheduling system, eliminating non-value adding activities and process bottlenecks, staff training, etc., were a few improvements executed in the cardiology department.

Consequently, the process capability improved to 3sigma, and the turnaround time was reduced to 240 minutes, with a standard deviation of 9 minutes. The Lean Six Sigma project delivered an annual cost saving of about Rs.3.4 million alongside increasing patient satisfaction to 91 per cent. Subsequently, the hospital’s top-management was overwhelmed to initiate several Lean Six Sigma projects in other hospital departments. Further, it contributed to learning, excitement in the participating stakeholders towards a cultural change. Customer centricity, process orientation, data-driven decision making were a few learnings highlighted by the participants.

Lean Six Sigma offers a unique methodology to solve complex problems. While it offers both process and data lenses to examine problems towards a resolution roadmap, practitioners endorse it to be easy to learn and effective when applied. It will be a worthy future direction for healthcare professionals like doctors, administrators, lab personnel, and other clinical and non-clinical technicians to learn and apply Lean Six Sigma for continuous improvement. Alongside practical management learning, it sets an agenda for total personnel participation towards building a continuous improvement culture (beyond individual projects), a critical gap to bridge, and a worthy opportunity to pursue in the healthcare space.

With digital automation, robotics, and information and communication technologies being applied faster in healthcare institutions, it is important for them to embark on the Lean Six Sigma journeys. As Garbage-In-Garbage-Out, automation of a bad process is still a bad investment that would not reap the expected return. Lean Six Sigma, a pre-requisite to technology deployment, would help hospitals and other healthcare institutions streamline their processes and improve them as deserving candidates for digitisation. It is important to start improving the health of the healthcare processes, as an essential agenda for healthcare practitioners. To this effect, we, at the Indian School of Business, are developing a Lean Six Sigma curriculum to enable continuous improvement capability among the healthcare practitioners.