Development of Lean Six Sigma Model for Hospital Industry

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1 Available online at GlobalIlluminators Full Paper Proceeding TMBER-2015, Vol. 2, FULL PAPER PROCEEDING Multidisciplinary Studies ISBN: TMBER 2015 Development of Lean Six Sigma Model for Hospital Industry Raju Ramaswamy 1, C Selvan 2* & S. Kalpana 3 1,2 College of Engineering, Guindy campus, Anna University Chennai Abstract The differences between operational excellence and business excellence are seldom bridged with productivity benefits and yearly targets by organizations in current scenarios, but they have not significantly touched or made a positive impact bringing delightful and easy customer experience. In recent time s public foru m reviews touches upon movies, restaurants and also books, as people today critique their experiences in whatever things and events they interact with in their daily life. A place that deals with people s health care systems definitely need a model to gauge their experience with patients, that helps them in their recovery process and hospitals to provide a better Quality of treatment and care.in India, Lean Six Sigma as a methodology, has been commonly used to solve simple to complex challenging scenarios predominantly in manufacturing industry, and is not used frequently as a practice evidenced in the hospital industry. The aim of this exploratory research was to assess the status of Lean Six Sigma implementation in hospital (services) industry specifically for India, thereby developing a practical model to facilitate successful implementation of Lean Six Sigma. A mixed method approach of survey and multiple case studies during phases of research was adopted to achieve the aim of the research by answering the following key research questions (RQs): RQ1: What are the Critical Success Factors (CSFs) for implementation of Lean Six Sigma in the hospital industry in India?RQ2: What would be the appropriate model that would assess the readiness to embark the continual improvement and provide a platform for continual improvement journey for the hospital industry in India? The adoption of a mixed method approach not only facilitated in answering the RQs, but also addressed the quality research criteria of reliability and validity for this research. This exploratory research had made some significant contributions to the theory and practice of Lean Six Sigma research in hospitals The Authors. Published by Global Illuminators. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Scientific & Review committee of TMBER Keywords: DMAIC; Lean Six Sigma Methodology; IMAGE, Financial, Clinical, operational Introduction Across the world, the benefits of Six Sigma has been well testified in many big manufacturing as well as service industries. Lean Six Sigma (LSS) is gaining momentum as one of the most effective business process improvement strategies among a large number of multinational organizations. To date, the benefits of LSS have primarily been realised by large organizations and the question therefore remains how best to apply Lean Six Sigma in a Hospital context. Healthcare being the indicator of any developed economy need to embrace new business strategies like Lean six sigma (LSS) that may have significant impact on their bottom-line results and bring about cultural transformation within their organization. *All correspondence related to this article should be directed to C Selvan, College of Engineering, Guindy campus, Anna University Chennai rraju@annauniv.edu 2015 The Authors. Published by Global Illuminators. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Scientific & Review committee of TMBER-2015.

2 The need for developing a customized continual improvement Model for Indian Hospital scenario arises with the fact that the expectation by the patients are in an ever increasing trend. The medico legal regulation also demands a defect free environment especially in the case of morbidity and death rates as an outcome of infections and medication errors. With such a rising expectation and upcoming demand, there was a strong desire to develop a continual improvement Model that would align and influence the areas of Financial, Clinical, Operational, Service excellence and Safety aspects in the hospital scenario. Care delayed is Care denied and hence to provide that aspect of tender loving care in a timely fashion at an optimum cost and zero defect environment, the vision of the research propelled the desire because of which the hospital business and the community at large would be benefited in various aspects of services offered. Hence an attempt was made through this research and a Model was developed to assess the readiness of the organizations to embark upon the continual improvement journey and provide with a customized methodology that would be more specific to the hospital industry. Literature Review Few studies have so far been conducted to assess the implementation of Lean and/ or Six Sigma in Hospital industries. Cagliano et al. (2011) have applied Reason s theory of failure and use of FMEA and waste analysis to work out a systemic approach for risk management in Hospital sector which aims to reduce failures and to improve patient safety. Cima et al. (2011) used LSS methodologies to implement process improvements in three different surgical specialties thereby increasing the operation room efficiency and financial performance. Thomas et al. (2008) have developed integrated LSS framework based on previous model which focuses on application of tools & techniques. Chileshe et al. (2007) have developed a systematic framework for understanding of TQM incorporate- Continual Improvement constructs &concepts, practices such as process management, and tools, techniques & values such as SPC and TQM. Khan et al. (2007) have developed a practical Business Process Improvement (BPI) framework and Performance Assessment Methodology (PAM) tool for UK organizations. BPI framework constituted six elements namely- vision, collate and measure, define and plan BPI (supported by management commitment, education, and support), management awareness, training and education on Kaizen, and checking the progress. Koning et al. (2006) combined lean with six sigma DMAIC methodologies to reduce the complexity in hiring personnel; reducing operation room starting times and improving the process of system maintenance. Deros et al. (2006) have developed conceptual benchmarking implementation framework whose key constituents were top management vision, soft and hard performance measures, tools & techniques, critical success factors, general methodology (PDCA), and business goals. Based on the literature review in the areas of Continual Improvement journey, Six Sigma (DMAIC), TQM, Lean, the following gaps were identified. The research aims only at financial and clinical excellence leaving a scope of improvement for service excellence and safety in surgical specialties (Cima et al. 2011) Lack of guidelines on how to operationalize the framework (Chileshe et al. 2007) 431

3 There is no customized framework for service Industry that would incorporate all the best practices of Lean Six Sigma and influence people management aspects (Kumar et al 2007) DMAIC methodology used in the study doesn t assess the readiness of the hospital to embark the LSS journey and the leadership change (Koning et al. 2006) Some elements of conceptual benchmarking implementation framework were not proven statistically (Deros et al. 2006) The lack of bargaining power against suppliers and lack of resources are major hindrances encountered when implementing TQM programs (Lee, 2004) Lack of resources [human, financial, technical] (Moreno-Luzon, 1993; Lee and Oakes, 1995; Haksever, 1996; Ghobadian and Gallear, 1996; Yusof and Aspinwall, 2000b ) Lack of visible leadership (Ghobadian and Gallear, 1997) Lack of vision, strategies and overall objectives (Lee and Oakes, 1995; Moreno- Luzon, 1993) Research Objectives Based on the extensive literature study and the identified research gaps (referenced in section 2.0) and extensive brainstorming sessions with eminent professionals in academy and industry helped in formulating the following objectives: - To understand the challenges prevailing in implementation of Lean Six Sigma methodology in Indian Hospitals. - To develop a customized Lean Six Sigma Model that would fulfill the needs of patients, stakeholders and community at large in an Indian Scenario. Research Questions The following research questions (RQs) aims at addressing the aforementioned objectives in section 3. The questions were formulated by appropriate usage of Delphi Techniques where a panel of 20 member expert team was engaged. RQ1: What are the Typical Challenges faced in the implementation of Lean Six Sigma methodology? Identification and prioritization of top challenges faced through mixed method case study and interview techniques. 432

4 RQ2: What would be the appropriate Model that wo uld assess the readiness to embark the continual improvement transformation and provide a platform for continual improvement journey for the Hospital Industry (for any Indian Service Organization)? This research question would address the most important part of research and would lead to the following two contributions To know whether the service organization (Hospital) is ready to embark on the Continual Improvement journey or not. To interact with the practitioners and develop a customized LSS model that would be appropriate for Indian hospitals. Methodology Based on the comprehensive knowledge obtained from the literature review, a phased approach as referenced in Figure 1. was adopted to embark on the journey of developing a customized lean six sigma model for the hospital industry. One case study was before development of the model and the developed model was tested in three of the hospital with one case study each. PHASE 1 PHASE 2 PHASE 3 STAGE1 STAGE 3 STAGE 6 EXPLORATORY S URVEY (PRE TES T WAS CONDUCTED TO TES T THE WORKABILITY) - Development of Survey - Shortlisting the hospitals based instrument - Inputs from literature on time and financial constraints review and industry professionals (Based on their choice obtained from Phase 1) nd - Identification of responses International from Conference 16 Hospitals on Trends in Multidisciplinary Business and Economic Research (TMBER- 2015) opportunities in the (Within India) Case study references selected (3/4) hospitals 433 STAGE 4 - Location of Hospitals: Chennai, Delhi, Hyderabad and Kolkata TO ASS ESS THE READINESS OF HOSPITALS TO EMBARK CI JOURNEY IDENTIFICATION OF VALIDATION OF IMAGE MODEL - Short listing the hospitals (Based on their interest to take up the LSS Initiative) - Testing the customized LSS Model (IMAGE)

5 Figure 1: Mixed method approach IMAGE Model Development of A Customized LSS Model - Image (I Initiate, M Measure, A Analyze, G Govern, E- Enable) Based on the, complexity and speciality and vision, Hospitals H1 (1 out of 4 hospitals) expressed their interest to participate in collaborative development of LSS Model). H1 was considered for the study initially The study revealed that the maturity of LSS for H1 was were very poor and the results achieved due to LSS was not significant as they addressed only the needs of emergency services. There was a need felt to develop an integrated continual improvement Model that would address the aspects of Lean, Six sigma, Change leadership, project management and other softer aspects. 434

6 Case Study 1 Reduction of Medication Errors was identified in hospital H1. DMAIC (Define, Measure, Analyze, Improve, and Control) was utilized to identify patient touch points and root causes. Results: Medication Errors reduced from 0.6 errors per dose dispensed to 0.14 errors per dose dispensed. Based on the comprehensive literature review on lean and six sigma (DMAIC) methodology and from the lessons learnt from the case study as referenced section 5.1, the model named IMAGE(Initiate, Measure, Analyze, Govern, Enable) was proposed. This was further developed by obtaining inputs from various practitioners and stakeholders within the two identified hospitals. Identification of positive influencers, obtaining top management commitment, formulation of specific goals aligning to vision, mission, ensuring that the goa ls are part of appraisal system, proposing appropriate incentive plans, formation of quality circles and developing appropriate rewards and recognition, having a very strong governance around the toll gate reviews were some of the lessons learnt from case studies which were incorporated in the IMAGE Model. Some of the interventions that were designed specifically to meet the needs of the hospitals was developed based on the outcomes of case studies would impact the areas of financial, clinical, operational, service excellence and safety aspects of any given hospital. Figure 2: IMAGE Model 435

7 - These Steps were designed specifically to the needs of hospitals * FCOSS Financial, Clinical, Operational, Service Excellence & Safety Post development of the IMAGE model there was a plan to further evaluate the effectiveness of model by way of deploying in three more hospitals as referenced in section 6.2, 6.3 and 6.4 respectively.for all the case studies mentioned Mann Whitney test was conducted at 95 % confidence level. Case Study 2 To improve the quality of care and patient satisfaction level by mining the patient s opinion and feedback data using the text analytics and identifying the problematic departments which were the major source of patient s dissatisfaction by deploying Lean Six Sigma Model (IMAGE). Figure 2.1: IMAGE Model for Reduction of number of complaints Figure 2.1 shows the detailed phase wise objectives of IMAGE Model to reduce the number of complaints. Similarly, detailed phase wise IMAGE approach was applied to other two case studies. The improvements after IMAGE Implementation were significant as shown in the Reduction of number of complaints case study. The sample medians of the ordered data were found to be 3 and 4 before and after IMAGE implementation respectively. The 95% Confidence level for the difference in population medians is [ , ] and p- 436

8 value = Since the p value is lesser than Alpha level of 0.05, there is sufficient evidence to reject H 0. Deliverables: Reduction of number of patient complaints from 577/year to 121 year. Case Study 3 A case study which highlights the impact of Information Technology (IT) -Service level agreement was identified in hospital (H4). By utilizing IMAGE Model and the availability was raised from 99.9% to 99.99% by reducing the average downtime of BIMS & PACS applications. The sample medians of the ordered data were found to be 2.5 and 4 before and after IMAGE implementation respectively. At 95% Confidence level p-value = Since the p value is lesser than Alpha level of 0.05, there is sufficient evidence to reject H 0. Hence there is a significant improvement post implementation of solutions recommended in case study through IMAGE Implementation. Deliverables: Reduced overall Application Downtime by 409 minutes / year to 230 minutes / year. Reduced BIMS Application Downtime by 113 minutes / year to 10 minutes /year Case Study 4 A case study based on improving the efficiency of laboratory services using principles of LSS was identified in hospital H5. The 95% Confidence level for the difference in population medians is [ , ] and p-value = Since the p value is lesser than Alpha level of 0.05, there is sufficient evidence to reject H 0. Deliverables: Before IMAGE Implementation: Laboratory TAT = 4.22 hours After IMAGE Implementation: Laboratory TAT = 2.10 hours The results of the case studies show that there is significant improvement post the solutions implementation in all the three hospitals where IMAGE Model was implemented. Contributions of the Research This research adopted a mixed method approach to contribute to the advancement in methodology application within the Lean Six Sigma research in hospitals. The Six Sigma body of knowledge was enriched through the following contributions: Development of a practical Lean Six Sigma model namely IMAGE (Initiate, Measure, Analyze, Govern, and Enable) aligning to the needs of hospital industry in India, to facilitate implementation and long-term sustainability of benefits realised from Lean Six Sigma. The literature is devoid of any such Lean Six Sigma model proposed for the use of hospitals in the Indian context. The work undertaken takes care of the Life cycle approach in a typical 437

9 hospital. There is a careful consideration of all the touch points of the customer (patient) considering the aspects of Cost, Service Excellence, Clinical, Operational and Safety aspects. The proposed model aims at reducing the variation and achieving zero defects (Medication error, Infection control) that would impact the human life. The results have been well validated in three hospitals and there has been a significant contribution by the model in improving the overall culture and adoption of Lean and Six Sigma as a way of touching and impacting lives. Limitations This research focused only Indian hospital industry to assess the current status of Lean Six Sigma implementation in hospitals. The sample selection was more towards the private sectors. Though a few government hospitals came forward the sponsorship and the keen interest was not shown because of budgetary constraints and medico legal regulations and data privacy challenges. Due to time and financial constraints, it was difficult to revisit the participating hospitals more than three times in the second phase of research. Any queries were dealt through telephonic conversations with participants in the case study. Scope for Future Research The limitation section introduced some of the limitations of this doctoral research, which could be improved in future to make the findings more generalizable to the larger population. Following items describe the scope for future research: 1. Increasing the scope of Lean Six Sigma research in hospitals by including hospitals from other countries and continents. This will provide a better picture of the status of Lean Six Sigma implementation in hospitals especially across Asia pacific countries. Also further based on the change in the policies of the government regulations and budgetary approvals the same Lean Six Sigma model can be further tested in government hospitals to further enhance the methodology. 2. While there are some specific areas of data analytics like text analytics and sentiment analysis that have been used as part of this study, other big data analytics tool set could be incorporated as an extension of IMAGE model for better insights and results as a next generation model. References Cagliano, A. C., Grimaldi, S., & Rafale, C. (2011). A systematic methodology for risk management in healthcare sector, Safety Science, vol. 49, no. 5, pp Cima, R. R., Brown, M. J., Hebl, J. R., Moore, R, Rogers, J.C., Kollengode, A., & Deschamps, C. (2011). Use of Lean and Six Sigma Methodology to Improve Operating 438

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