Use Lean Six Sigma to Enhance ‘Flow,’ Add Value to Anesthesia Care

SUMMARY The rigorous process improvement methodologies known as Lean and Six Sigma have countless applications in healthcare and have been used to improve many aspects of anesthesia care. Anesthesia providers might want to consider employing these approaches in their quality improvement efforts.

Hospitals and healthcare practices have used the Lean and Six Sigma process improvement methodologies separately and in blended form to tackle processes and problems of many kinds. Originally developed in manufacturing (by Toyota and Motorola, respectively), these systematic approaches to continuous quality improvement have been applied to ferret out waste in anesthesia supply chains, reduce turnaround times for pathology reports, streamline preoperative clearance of patients, increase cafeteria customer satisfaction and much more.

Are your quality and process improvement strategies working for you? If not, you might want to explore opportunities to learn and incorporate these robust methodologies into your arsenal. Many anesthesiologists are already working in Lean environments. You might also consider initiating collaborative efforts with surgery, nursing and other departments at your institution using these techniques to improve efficiency, increase quality and reduce the costs of care.

Lean is designed "to maximize customer value while minimizing waste," according to the Lean Enterprise Institute. "Simply, Lean means creating more value for customers with fewer resources."

Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects (driving toward standard deviations between the mean and the nearest specification limit) in any process—from manufacturing to transactional and from product to service.

According to a survey of 77 hospitals by the American Society of Quality (ASQ) in 2009 (the most recent year for which data is available), many healthcare organizations have only begun to use Lean and Six Sigma as quality improvement methods. Among the survey's findings:

• 53 percent of hospitals use some form of Lean.
• 4 percent of hospitals have fully deployed Lean.
• 42 percent of hospitals use some form of Six Sigma.
• 8 percent of hospitals have fully deployed Six Sigma.
• 11 percent of hospitals are not familiar with Lean or Six Sigma.

"When healthcare costs continue to rise, it is crucial that U.S. hospitals look to methods like Lean and Six Sigma to become more efficient," said James Levett of ASQ. "This study indicates that many healthcare systems are still in the 'infancy stage' when it comes to using these vital cost-cutting tools."

Though the process improvement methodologies have driven significant improvements for many healthcare organizations, "it's fair to say the industry as a whole has merely scored a series of 'first downs,'" said consultant Ian R. Lazarus in a 2012 article in Becker's Hospital Review.

And yet, the strategies have a great deal to offer the healthcare sector, where safety and efficiency are paramount. "In the world of quality improvement, complexity is an unparalleled source of waste, delays and errors in processes," consultants Kimberly Watson-Hemphill and Kristine Nissen Bradley wrote in Quality Digest. "Some complexity in healthcare organizations is imposed from the outside by regulations, insurers, and government agencies, and there may not be much that they can do about that. But there is also a significant amount of complexity that is self-induced—and that can be addressed with Lean Six Sigma."

Less Waste

According to consultant Owen Dahl, FACHE, a presenter at a recent Lean Six Sigma webinar sponsored by the Medical Group Management Association (MGMA), it is generally recognized in the quality improvement field that about 25 percent of an individual employee's time is wasted each day. Moreover, according to research reported in a Health Affairs Health Policy Brief, "Reducing Waste in Health Care," an estimated 30 percent of all Medicare clinical care spending is unnecessary or harmful and could be avoided without worsening health outcomes. In a 2012 report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America," the Institute of Medicine calls for an expanded commitment in healthcare to continuous learning and improvement in order to reduce this waste and improve quality. Lean Six Sigma is one of the quality improvement techniques that can support continuous learning.

An August 2016 article in American Nurse Today offers a useful description of the distinctions between the two approaches. While Lean is "an integrated system of principles, practices, tools, and techniques that aims to eliminate waste, decrease production time and improve process efficiency," Six Sigma focuses on deployment plans and analytical tools (including statistics) to reduce variation and deviation from the mean. Lean's strengths lie in "engaging front-line employees to develop standardized solutions to common problems" while Six Sigma focuses on identifying and correcting the causes of errors. Stated another way by Dahl, "Lean looks at gaps or roadblocks in your processes, whereas Six Sigma looks more at the defects of broken parts."

Basic Concepts

Dahl and co-presenter Alti Rahman of Oncology Consultants highlighted the fundamental tenets and practices of Lean Six Sigma in the webinar. These include:

• Value Concept: Value is defined by the customer (patient) and by what the customer is willing to pay for.
• Value Stream: the idea of bringing value back to the patient and recognizing they have a voice in the services provided.
• Flow: the smooth movement of processes in an organization. Flow refers not only to patient flow, but also to the processes related to everything from how employees answer the phone to the hiring of employees and the credentialing process.
• Pull: the idea that, as one step in a process is complete, the next step is ready to "receive" and complete rather than hinder or block the process (a concept referred to as "push").
• Perfection: the ideal that will never be achieved but for which the organization always strives.
• Value Stream Mapping: analyzing the current state of a process and designing a future state for the series of events that take a process from beginning to end.
• Touch Points: the interactions with a patient. Every time a clinician or hospital employee interacts with a patient, they are "touching" the patient.
• Tipping Point: the point at which a series of small changes or incidents becomes significant enough to cause a larger, more important change. In healthcare, the tipping point is determined by the touch points that together make up the patient experience. The tipping point can be positive or negative.

Also fundamental to Lean Six Sigma is the DMAIC (Define, Measure, Analyze, Improve, Control) methodology that provides the five-step structure or deployment platform for every Lean Six Sigma project. Many hospitals use a similar four-step "Plan, Do, Study, Act" variation of this methodology that also has been shown to work well.

The "define" or "plan" phase of Lean Six Sigma projects begins with the creation of a project charter that describes the problem, defines project goals and process measurements, identifies start and anticipated end dates, and names the project using key words so that it can be easily found and used as a best practice in the future. (More information about project charters and a downloadable template are available here.)

Ingredients of Success

Consultant Lazarus provides the following checklist in Becker's Hospital Review for a robust Lean Six Sigma program:

• Staff trained in both Lean and Six Sigma methods
• Establish ROI expectations from portfolio of projects
• Sponsor training for senior management
• Visibility across enterprise for program and its achievements
• Celebration and recognition for completed projects and project leaders
• Implement formal handoff from project leader to process owner
• Continue running control charts on all completed projects
• Implement specification limits that identify if performance has regressed
• Create governance for program to approve new projects
• Communicate expectations for staff to complete at least one project annually (more if the staff are dedicated to performance improvement)

According to Rahman, a common argument against Lean Six Sigma is the expectation that it will be too time-consuming. Although the approach does require a commitment, as well as leadership buy-in, taking the time to plan a project and define the scope of a problem using the methodology's tools and techniques ultimately enables a group to move ahead on projects more quickly. The development and implementation at his organization of a charge process interface without the aid of a project charter took three times as long as the development of a much more complex drug dosing interface for which the team created a project charter and spent two weeks planning, he said.

Dahl and Rahman advise organizations new to Lean Six Sigma to think first in terms of a small project, develop a project charter for it and move through the DMAIC methodology.

Applications in Anesthesia

Lean Six Sigma principles were used to address deficiencies in the anesthesia supply chain at a pediatric hospital. Researchers applied DMAIC to define problems, map processes and gather input from staff members. Daily distances walked by anesthesia technicians and the number of callouts for missing supplies were measured before and after improvements, including redesign of the anesthesia cart. The project yielded efficiencies that persisted one year after implementation. In other studies, one institution combined the principles of Lean and Six Sigma to improve workflow in a postanesthesia care unit, another used Six Sigma statistical methodologies to significantly increase compliance and reduce variation in perioperative safety protocols, and a third employed Lean to improve on-time starts and reduce resident work hours in the vascular surgery suite.

The Surgical Process Improvement Team at Mayo Clinic, Rochester, combined Lean and Six Sigma methodologies to construct a value stream map of the entire surgical process from the decision for surgery through discharge. Process redesigns yielded significant improvements in on-time starts and financial performance. The authors attribute the project's success to process mapping, leadership support, staff engagement and sharing of performance metrics. The improvements were sustainable and transferrable to other specialties.

Some organizations find one methodology more useful than the other and prefer not to use both. Melissa Lin, a continuous improvement specialist at Virginia Mason Institute, notes that Six Sigma's data collection requirements can create "analysis paralysis," in which time and resources are spent adhering to the methodology's statistical requirements rather than making quality improvements as quickly as possible for the benefit of patients. For this reason, Virginia Mason uses the Lean methodology.

"Lean work takes rigor, and collecting and measuring data is an essential part of the Lean process, but the work is not centered on a time-consuming process of gathering and analyzing statistically significant statistics," she says in an article on the Institute's website. "It's about creating a system in which all employees in the organization are empowered to collect and measure data, and to create their own—and not a certified consultant's—improvement ideas. . . The data they collect and measure is meaningful to them and to all of their colleagues involved in the improvement work."

Still, many quality improvement experts believe the techniques can be used in tandem. Six Sigma's focus on variation and errors and Lean's focus on waste and inefficiency can yield important synergies that can improve quality, reduce costs and bolster patient and employee satisfaction.

Find out more about our anesthesia billing and accounts receivable services. 

With best wishes,

Tony Mira
President and CEO