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0 Introduction1.1 AimTheaim of this report is to explore Six Sigma techniques that can be applied in ahospital. It will cover how to approach implementation and the impact toexpect.

1.2 Six SigmaSixSigma is a powerful tool used to drive wide spread improvement across anorganisation, encompassing a range of different tools and techniques. Six Sigmaoriginates from the manufacturing sector. The aim is to reduce defects, andin-turn improve financial outputs and customer satisfaction. This philosophycan be adapted to any industry. A very important aspect to understand whenconsidering Six Sigma applications is that it is an on-going evolution ofmethods and approaches, which fluidly links with other quality techniques foroptimised business outputs. In specific cases the most effective tools to beapplied in order to identify inefficiencies in a process and to optimise thesewith a customer focus may vary. 1.

3 Qualityfor a hospital customer When thinkingabout quality for the customer it is important to consider both patients andhospital staff. Whilst the patient is the ultimate customer, the satisfactionof the hospital staff is closely linked to the quality of the care that theyreceive. Unlike in other industries where cost to the customer is a key elementof satisfaction, cost is rarely a factor for patients in the UK. This isbecause most patients are funded by the NHS or by private medical insurance. Asa result there is a greater emphasis on quality of care, in understandingsatisfaction. Quality covers experiences across a patient’s full journey:before and during hospital admission, and in recovery following discharge.

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Customer satisfaction metrics encompass improvements to health, time throughhospital stages, expectations management, and general experience (e.g. attentivenessof staff, cleanliness of environment and food).1.4 Qualityimprovement in HospitalPatientflow through the hospital is a complex process involving multiple differentdivisions. Each step in the process is vulnerable to introducing inefficienciesinto the system.

There are two different patientflow journeys to consider. One is emergency either via ambulance or via Adepartment, and the second is planned care, known as elective. These twopatient journeys are closely linked as they commonly use the same resources, inparticular beds and operating facilities, and require input from overlappinghealth care professionals. This means when making improvements in one patient journey,the other must also be considered to ensure no secondary negative sideeffects.  Sub-processes can beconsidered with respect to time including time to: arrive, assessment,treatment, departure or admission, assignment of bed/ward, and discharge 1.

Hospitalcapacity and occupancy impact patient flow. As a result, delays, particularly withoutappropriate explanation, reduce customer satisfaction. 2.

0 Recommendedtools and techniquesSixSigma is an on-going development always seeking new techniques for quality, andevolving methodologies and approaches for improvement. Thismeans individuals in charge of a Six Sigma project should regularly review the latestmaterials, as well as ensuring there are incremental improvements. Significantlong-term improvement takes time and requires a commitment to the project thatis sustained even during initial phases, where benefits are yet to be seen. TheSix Sigma framework DMAIC (Define, Measure, Analyse, Improve, Control) is usedto systematically work through the goals, objectives and performance of abusiness to analyse and improve processes.

2.1 DefineTobegin the project must be defined. Through understanding the vision, missionand values of the organisation, the strategic objectives can be outlined. Usingcompany statements ensures that the project resonates with the company strategy2.

The scope, schedule, deliverables and team approach can consequently bedetermined by understanding how the process works and who it involves andaffects. Once this is realised the most appropriate methods can be established.Thevoice of the customer (VoC) should also be considered when determining the bestmethods. This will combine both feedback about the experience and expectationof the service, from data collected in surveys, questionnaires and focus groups.Understanding the VoC in a service industry is slightly more complicated thanin the manufacturing industry, as it is extremely subjective and can varysignificantly on a case-by-case basis. Looking specifically at the hospital,raises even more problems as expectations can be drastically outside reality.For many people, healthcare is not a service frequently used, which means thereis nothing to compare the quality of the service provision to. Recording theVoC is also difficult, as often patients are not in the right state or cannotsee the bigger picture in order to accurately complete surveys orquestionnaires.

The Friends & Familytest is used to record a more objective view, as the patient rates if theywould recommend the hospital to friends 3. Patients may have negativefeelings about being at hospital, but this question allows them to recognise ifit was still good treatment they received.Thesetools are most appropriate as it encompasses perspectives from the organisationand hospital users.2.2 MeasureOncethe objectives have been outlined and processes understood, techniques tomeasure these factors must be applied for statistical analysis.

The processes measured can be chosen to helptranslate the VOC and will aid development of explicit targets and outputs.TheSix Sigma goal is to reach a level of 3.4 defects per million opportunities. Inthe manufacturing industry this quantified target is easy to understand and aimfor, where defects can be identified as waste material, rework, design flawsetc. which all have direct links to cost waste. Poor quality operation incurs additionalcosts of staff time, operational cost and additional material for example.

Thistarget is more difficult to interpret in the context of a hospital. Whendealing with someone’s health, prescribing the wrong drugs or performing anoperation not to protocol can result in death. In healthcare, there should beno tolerance for poor quality as it risks a life. Thorough understanding of theproblems, customer requirements and expectations in the healthcare sector willempower stakeholders to take action to a positive change with reduced processvariation. Control chartsare an essential tool for this step to determine when variation is due tocommon-cause or special-cause variation. This tool is preferred as it caneasily identify variations due to different timings, for example a slower timeto be assessed on the weekend as there is higher demand relative to the numberof hospital staff that are working.UsingSPC (statistical processes control)to measure sub-processes of patient flow will allow hospitals to understandwhere there is variation and where to intervene to achieve an overallimprovement.

The hospital should include benchmarkingin their SPC analysis, to allow them to compare their performance with others.This encourages knowledge sharing and questioning between hospitals which canhelp develop guidance on how to better improve sub-processes. SPCcharts fit data in relation to three lines, the mean line which is positionedbetween the upper control limit and lower control limit, UCL and LCLrespectively. These limits are set as a function of the data and can beidentified through past data and by defining common cause variated data points.Toget the most out of SPC, rules must be followed to assist the analysis of datato identify is there is special-cause variation in the process 4. 1)     Apoint outside of the control limits.

2)     Morethan 6 points consecutively above or below the mean line.3)     Atrend of 6 points, i.e. continual increase or decrease of points4)     Lessthan 2/3rds of points fall inside of the middle third zone around the meanline.

Ifone of these rules has been broken, the special-cause can be explored byfinding where on the timeline it is occurred. Investigating factors such as day,time, who was on shift etc. will enable the problem to be identified. It can beeradicated from the process.

Oneexample of use for an SPC chart with benchmarking would be for the measurementof average time waited for assessment. The process to assessment is importantas a patients’ health and condition canrapidly escalate with delay, which may result in immediate complications oradditional needs down the line. It is also an important contributor to patientsatisfaction and experience, as a being seen by a doctor quickly reducesconcerns and ensures patients that their needs have been noted. 2.3 AnalyseInevitablythere will be variation through-out and across many processes within thisproject.

Pareto analysis of theresults from SPC chart measures will highlight what focusses have the potentialfor the most improvement. Pareto’s Principle states that “80% of the effectscomes from 20% of the causes” 5. Figure 1 below shows an example of howPareto analysis has been applied for analysis of a company’s website.

This isused as reference to understand how to identify what causes to focus on. Figure 1: Website example using pareto analysis 6. Asshown on the diagram, the bar chart indicates the count error for each cause offailure. The red line is associated with the right-hand-side vertical axisshowing the cumulative percentage of total errors. By drawing a horizontal lineat 80% to the cumulative percentage line and finding where it intercepts thenshows the most important causes on the left-hand-side on the horizontal axis.Root-cause analysisusing ‘the 5 whys’ reveals different layers of the problem until you reach theroot, as you continuously ask why (5 as a rule of thumb). It ensures that the truecause is tackled and not symptoms of the problem.

This tool is reliant on thatthe right questions are asked and answers aren’t assumed or rushed toconclusions. Using the sub-processes of patient flow previously mentioned, anexample can be drawn from delay to initial assessment. Why:·       Noconsultant was available. Why?·       Theappropriate consultant was arranging discharge for another patient. Why?·       Noplans had been set into place. Why?·       Theresponsibility does not directly fall to anyone.

Why?Inthis case setting up a process by which a plan for an inpatient’s discharge isinitiated from the beginning will reduce the strain on consultant’s work load.Using root-cause analysis is also beneficial as it will uncover potentialcauses associated with multiple problems, emphasizing the influence on totalproject improvement that could be experienced. 2.4 Improve Thisstage takes everything that has been learnt from the previous steps, bringingit together to brainstorm different solutions to develop, test, review andimplement to address the outlined problem statements and root-causes. Brainstorming is a useful tool tocreate new ideas to resolve process problems. However, it is only effective ifcarried out in a judgment-free, creative environment, where everyoneparticipating feels comfortable to suggest ideas, without it turning into adebate but instead building and reflecting off each other 7.PDSA (plan, do, study, act)is a cyclic framework which is proven very useful to test out changes on asmall scale before total implementation. It is important to remember from thedefine stage the mission, vision and value statement as this should resonatethrough the solution strategies.

The first task is to record all actions thatinput into the change solution. Then review the impact, by running the test,noting all results, how it compared to predictions and what can be learned. Itis important that the solutions have measurable outputs or benefits so that wecan have continuous learning and identify the success of the plan. From this,amendments can be made to the next cycle and eventually lead to fullimplementation. This should be repeated for each solution identified in the analysestage.The Kano Modelshown in figure 1, can be used to illustrate requirements and expectations. TheKano Model has limited benefits as it does not give any suggestions on ideasthat would lead to improvement. A customer, patient, will expect to be takencare of and given appropriate treatment.

It is difficult to outline excitementqualities in healthcare, as it can coincide with expectations. However, usingthe model can be useful in this stage, to ensure that all the spoken, andun-spoken requirements are still accounted for whilst pursuing a new strategy,which introduces excitement qualities. Figure 1: The Kano Model 8 2.5 ControlHavinga control process in place is crucial in ensuring every step of improvement andsuccess is maintained and to lead to an ethos of continual improvement andlearning. Using tools mentioned previously, such as SPC, on an ongoing basis willmean that variation can continually be checked and reduced. Continual learningby using PDSA is key, and leads into SDSA which stands for ‘standardise, do, study, act’. Thisemphasises an important concept, that changes introduced become normal andwidespread throughout the hospital and can be shared with other hospitals.

SixSigma application should not end here but be a continuous cycle through theDMAIC framework. Updating as the VoC, and company statements change anddeveloping as excitement attributes transition to performance attributes. 3.0    Expected Improvements and Mechanism of ImpactNHShospitals in the UK are mainly publicly funded and receive most of their incomebased on their activity.

A tariff system is in place which mean there are setprices for different types of appointment and procedure. This means that thedynamics for increasing financial gain are different to many other industries,for example manufacturing. Across the country, hospitals are facing significantfinancial pressures which result in restrictions being placed on theorganisations by the regulators and commissioners. By managing costs moreeffectively hospitals can improve their efficiency avoiding regulatoryrestrictions and ensuring funds are spent in a way that benefits patients andstaff. Definingthe scope of the project is very important to ensure that the task ismanageable and reflects the needs of everyone involved. As customersatisfaction is heavily influenced by actions of staff and the quality of theintervention from arrival to discharge, the processes in the hospital must runefficiently. Thehospital has a duty of delivering high quality healthcare, available toeveryone.

Core NHS values include demonstrating compassion, acting withintegrity, listening and supporting other and striving for excellence 9. Aprominent issue preventing the provision of this is slow patient flow. Startingat the ‘end of the line’, prolonged patient stay can be introduced by delayeddischarge.

This occurs when a patient cannot be discharged from hospitaldespite being medically fit, which means they continue to use the hospital bedfor longer, preventing other patients from being admitted into the hospitalward. Whilst multiple individuals across teams in the hospital work to find asolution, other patients are disrupted. Planned surgeries are commonlycancelled if there are not enough beds available for recovery post procedure.These ‘bed blockers’ also have a significant impact on A&E waiting times,where patients with significant needs may have extended waiting times as thereis a limit in beds for them to be admitted to. Not only can each processintroduce delay but can severely influence the waiting times in the otherprocesses. The large interdependencies compounds the inefficiencies broughtinto the system. Inhealthcare, given there are so many different services being run, totalefficiency is hard to achieve. SPC is essential in measuring process variationand enables analysis to identify special-cause variation.

The human element ofthe processes challenges the extent of what can be achieved but efforts toeliminate special-cause and reduce common-cause variation can improveefficiency. If inefficiencies in a hospital processes are reduced, this willallow better allocation of staffing, so that there are enough to cope with thedemand, but not too many that morale drops because staff members areunderutilised.SPCcharts recording the following data would be recommended, for patients arrivingat A&E:i)               Time to assessment ii)             Time to admissioniii)            Number of patients admittediv)            Time to assignment of bed and wardv)              Time to treatmentvi)            Time to discharge vii)          Staff sickness daysviii)        Satisfaction scores from friends &familyAsimilar set of charts could also be created for planned procedures. In additionto the metrics above, with planned procedures it will be important to measurethe number of cancellations (where warning is given) and ‘Did not Attend'(where no warning is given) rates.SPCcharts of the suggested data would provide an insight into where problems arisein patient flow, and promote progress towards the NHS goal of a 4-hourperformance window in A&E 10. Charts vii and viii don’t directlyinfluence patient flow, but are important aspects in providing care in ahospital, relating to satisfaction of staff and patients.

A happier work force,with new strategies for more effective processes, reducing delays should resultin happier patients and families.For example, creating amore efficient process for a patient’s journey, by minimising a patient’s timethrough hospital. This will have significant benefits for a patient and reducescosts for the hospital.

The hospital incurs additional costs for everyadditional day that a patient spends in hospital, without receiving anyadditional income given the tariff system used by the NHS 11. Furthermore,when a patient spends more days in a hospital that is medically fit it preventsother patients with higher needs, who would bring additional income for thehospital, from using the bed. This is commonly referred to as ‘bed blocking’ 12and causes huge pressures in winter months when demand in A departmentsis particularly high. 4.

0    Supporting FactorsApplyingSix Sigma techniques with a systematic approach through the DMAIC framework isvery important. Picking and choosing only a few of the tools discussed inSection 2 will not reap maximum benefits as important elements in understandingwhat the problem is, why it is happening, how to solve it, and how to keep thecustomer at the focus could be lost. Implementationof all these processes requires training. Communication between patients,hospital employees, stakeholder, and Six Sigma Champions must be clear andcoherent. It is important that the use of technical jargon is avoided and ifnecessary explained plainly. This is because if made too complicated theconcepts, and new strategies will be totally discarded.

Continual training isessential to ensure that the hospital is always pushing for improvement.Thereis often a pre-conception that improved quality costs more, but if managedcorrectly, quality improvement should drive cost benefits. This highlights animportant aspect in introducing Six Sigma that training should not just coverhow to implement the tools and instructions of new strategies for improvement,but also education into the broad plan of the problems, and the impact changewill have.

For example, if a patient receives high quality intervention and treatment,the chances of emergency readmission, or the need for follow up appointments isreduced and hence there is less demand and cost associated to that patient 13.Some processes have time pressures associated with them, it is important thatstaff education in understanding that rushing and undercutting, will notgenerate improvements. For example, rushing initial assessments, so that morepatients can be seen quicker, can introduce serious complications if misdiagnosed,and increase costs on wrong treatments or prescriptions. 5.

0    ConclusionFrom this report, asystematic approach of tools and techniques has been discussed, identifying theDMAIC framework as essential. Defining the scope through organisational goals,as well as keeping the VoC as a focus, creates targets for development andidentifies what factors are not meeting expectations. SPC is a vital tool inmeasuring process variation, highlighting inefficiencies throughout thehospital. It is a tool which can easily be analysed to help remove/reducevariation.

Pareto and root-cause analysis help to find the underlying problems,which can be eradicated through brainstorm new strategies. Ensuring thisprocess is continuous and maintained is critical to keep a continuous improvementsystem. Achieving less variation in a process, means that it will be moreeffective and efficient and through a better utilisation of staff andmaterials, a better healthcare environment will be provided for patients. Thiswill lead to a much higher customer satisfaction rating and better careintervention. Reduced time through patient journey will decrease strain anddrive costs down, achieving financial gains.

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