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October 30, 2006
Sluggish HIM departments can receive a pick-me-up by taking a page from one of four process improvement models. We all know the drill. The boss just got back from a seminar on performance improvement and now you’re expected to adopt the latest fad. “Oh no, not another change,” can be heard from staff throughout the department. There’s no denying that over the past two decades healthcare organizations have employed various improvement methods to achieve quality and patient safety gains. We’ve promoted teamwork through new reward systems, trained staff in quality management principles, reengineered HIM processes, and developed balanced scorecards. Simplification, streamlining, and accountability have become commonplace buzzwords in the quest for better performance. But before you cringe at the thought of another performance improvement initiative, remember the old adage, “When one door closes, another opens.” What we’ve learned over the years is that there will always be new and better process improvement tools and techniques. HIM professionals must seek to understand the purpose of various improvement models so the valuable aspects can be incorporated into improvement initiatives in the HIM department. In the past few years, a plethora of process improvement methodologies have been introduced into the business world and some are beginning to be applied in healthcare. Four currently popular models are: Kaizen, rapid cycle improvement (RCI), Six Sigma, and lean thinking. To select the right approach for a particular improvement project, it is helpful to understand the primary theory behind each model, its focus, and the intended effect of the improvement efforts. Figure 1 (page 22) is an overview of the four improvement models. The tools and techniques in these improvement methodologies can help HIM departments find better ways to solve problems, improve efficiency, reduce mistakes, satisfy customers, and, best of all, innovate. These methodologies are really nothing more than names given to a collection of tools and scripted improvement techniques that can be integrated with a department’s existing process management activities. Cross-training in the multiple methodologies can help ensure that the right tools are applied at the right time and place. Kaizen Kaizen activities can be conducted in several ways. First and most common is to change processes to make the work more efficient or safer. Employers are encouraged to be actively involved in process improvements with the help of colleagues or a Kaizen support group. The second way is to improve the equipment used by employees. For example, by installing chart tracking software or switching to wireless charting tablets. Another aspect is to improve the procedures employees are expected to follow. All these alternatives can be combined in one improvement initiative. Application of Kaizen to a process improvement initiative follows a pattern similar to traditional improvement models. Depending on the project’s objectives, there are many ways to implement the Kaizen procedure. The following are the common project steps: • Form a Kaizen team and gather information. In this step, the facts of the process are examined (start and end points, customer requirements, etc). • Describe the current process by using flow charts or other process diagrams. • Decide the improvement goal. After gathering detailed information about the current process, the team identifies the specific improvement goal. • Develop alternative solutions. The Kaizen methodology suggests that seven alternative solutions be developed. • Evaluate and select the best solution. This is a data-driven step in which the team considers the advantages and disadvantages of the alternative solutions developed in the previous step. • Evaluate the best solution. To confirm the possibility of implementing the solution selected in the previous step, the change is pilot-tested or simulated. • Estimate benefits, including cost savings, efficiency improvements, error reduction, etc. • Results and analysis. Continue to monitor the process to confirm the solution achieved the expected benefits. In 1985, Masaaki Imai, in his book Kaizen: The Key to Japan’s Competitive Success, was the first person to introduce the concept of Kaizen outside Japan. Since then, Kaizen has become a well-known and widely used philosophy in organizational improvement. Imai offered 10 basic tips necessary to begin the journey of Kaizen implementation in an organization: • Discard conventional fixed ideas. • Think of how to do it, not why it cannot be done. • Do not make excuses. Start by questioning current practices. • Do not seek perfection. Do it right away, even if for only 50% of the target. • If you make a mistake, correct it immediately. • Do not spend money just for Kaizen; use your wisdom. • Wisdom is the result of being faced with hardship. • Ask “why?” five times and seek root causes. • Seek the wisdom of 10 people rather than the knowledge of one. • Kaizen ideas are infinite. RCI Setting the aim involves taking a clear and deliberate look at what is to be accomplished. Questions that can help the project team establish aims include the following: • Is it measurable? (Will we know whether it was achieved?) • Is it a “stretch” goal? • Is it right for the time frame? • Is it consistent with the organizational mission? • Does it matter to patients and families? • Can we think of at least a few things to try that will help achieve the aim? • Does the project team match the aim? • Is it outcome-oriented? The aim, or goal, drives the next step: defining the measure. The measure describes what the process should be able to accomplish if a solution is successful. Key measures that operationalize the aim are chosen. For example, for the goal of improving patient satisfaction in a hospice unit, a measure may be average time from pain assessment to administration of medication. The third step is to select process changes that are expected to achieve the aim. Ideas for process changes can come from many sources: project team members, frontline staff, literature, other organizations, professional colleagues, etc. The last RCI step is to test the changes using a rapid-cycle PDCA process. The process is considered “rapid cycle” because the team focuses on small, concrete changes that can be quickly put into action in a pilot situation. Thus, the solution can be evaluated in a short time. If the changes don’t work, another PDCA cycle is initiated until a workable solution is found. Rather than conduct a comprehensive—and often time-intensive—analysis of a process, RCI relies on small process changes and careful measurement of the effect of these changes. This PDCA approach utilizes an accelerated method (usually less than four to six weeks per improvement cycle) to collect and analyze data and make informed changes based on that analysis. This is then followed by another improvement cycle to evaluate the success of the change. The ongoing repetition of these improvement cycles serves as the basis for continuous improvement and allows for the creation of internal performance benchmarks. Because RCI is based on the PDCA model, most people are familiar with the tools and techniques used for the improvement projects. An added benefit of using RCI is that only those people or departments that tend to be early adopters of innovation need to be involved in the pilot tests of process changes. If these pilot studies are widely visible and the data support the value of process changes, the “late adopters” are more willing to support the changes. The RCI model is being utilized by many healthcare improvement initiatives, including breakthrough projects sponsored by the Institute for Healthcare Improvement and the Medicare quality improvement initiatives sponsored by the Centers for Medicare & Medicaid Services and overseen by the Quality Improvement Organizations. RCI has been successfully applied to both the operational aspects of healthcare delivery as well as clinical patient care processes. Six Sigma Six Sigma has its foundation in total quality management philosophies and incorporates concepts from many other approaches such as reengineering, balanced scorecards, voice of the customer, and design of experiments. One major contribution of Six Sigma is a reorientation to the definition of what constitutes “acceptable quality.” Six Sigma is the term used in statistics to denote a 99.9997% defect-free yield for a process. The concept has long been applied to manufacturing processes. In recent years, however, healthcare organizations have begun to use the tools and see results. Key characteristics of the improvement methodology are as follows: • Process variation control — To achieve an almost perfect level of quality, Six Sigma focuses on reducing the variations that can occur in a process. The gap between process capability and how the process currently performs is seen as an improvement opportunity. • Results-oriented — The potential impact on performance (financial, clinical, operational) is projected prior to the start of a Six Sigma project and an evaluation is made at the end to determine whether the goals have been met. • Data-driven — Detailed information about the process is gathered and analyzed to reveal defects in procedures that, once corrected, will allow the process to operate within six standard deviations of average performance. Initiation of a Six Sigma project is similar to any performance improvement activity. Leaders select projects based on the organization’s strategic goals and the likelihood that the project will lead to significant improvements. Six Sigma projects follow a highly structured and disciplined process, typically the DMAIC (pronounced dee-MAY-ick) methodology. This process improvement method involves five steps: define the problem, measure the problem, analyze the data, improve the system, and control and sustain the improvement. Each DMAIC step has defined goals, critical checkpoints, and relevant process improvement tools. Active leadership oversight is important to ensure the project stays on track, adequate resources are allocated, and the steps are completed with sufficient rigor. Six Sigma projects in healthcare organizations tend to focus on the operational aspects of service delivery rather than the clinical decision-making process. Examples of processes selected by hospitals for Six Sigma projects include the following: • patient registration/admission; • patient flow/bed control; • turnaround of diagnostic test results; • timeliness of emergency department treatment; • surgery scheduling; • inventory control; • supply chain management; • billing accuracy; • insurance denials; and • human resource management. Lean Some quality specialists view Kaizen and lean thinking as synonymous since the goals of the process improvement activities are similar—reduce costs, improve quality, and decrease cycle time. The basic principles of lean thinking are as follows: • eliminate waste (retain only value-added activities); • concentrate on improving value-added activities; • respond to customer concerns; and • optimize processes across the organization. The fundamental objective of lean thinking is to provide perfect value to the customer through a perfect value creation process that has zero waste. Another view is that everything done in the HIM department should add to the value of the services provided to customers. Some activities are of obvious value (retrieval of patient records) while others seem far removed (collection of hospital statistics). However, errors in the collection of statistics can detract from the department’s ability to meet the internal customers’ needs. Lean thinking encourages viewing every activity to ensure it is supporting a customer—regardless of whether the support is direct or indirect. To translate this concept to the HIM department, management needs to shift its focus from optimizing separate tasks or activities to optimizing the flow of an entire process or group of linked processes. The goal is to eliminate waste along the entire “value stream” of a process instead of improving just the individual steps. The simplest versions of lean thinking involve little more than a quick look at a process followed by some immediate changes based mainly on subjective decisions. While this produces change quickly, long-lasting performance improvement is unlikely. At the other extreme is a massive data collection effort that includes a comprehensive analysis of process flow. This can take several months or even years to complete before any actual changes are made. The ideal use of lean thinking is somewhere between these two extremes. It is critical to do enough data collection and process analysis to improve the process based on facts, not opinions. The amount of data required will depend on the nature and condition of the processes. Optimizing the process flow comes from having the right data and knowing how to use it. Value-added activities are those steps in a process that contribute to the organization’s overall goals and business objectives. Fundamentally, “going lean” is a process improvement methodology that involves two primary steps: 1. Analyze the steps of the process to determine which steps add value and which do not. This involves asking questions such as the following: • Does this step create value for the customer? • Is it capable of producing a good result every time? • Can it produce the right result at the right time? • Is the capacity adequate so wait time is not excessive or is there too much capacity? 2. Link the value-added steps to optimize process flow and eliminate the unnecessary steps. This involves asking questions such as the following: • Do all the steps in the process occur in a tight sequence with little waiting? Does the information flow smoothly? • Does each step only occur at the command of the next downstream step within the time available? • Are demand signals filtered to remove unnecessary variation and levelled to smooth the workload? While lean thinking may appear to be a process improvement
model that is only applicable to manufacturing, it is being successfully
applied in healthcare organizations. Often, lean thinking is a natural
complement to Six Sigma. For example, the data gathered in the analysis
of process flow can be used to identify high-priority/high-impact areas
for Six Sigma projects. • Makes use of measurement and statistical analysis. This is the scientific approach to process improvement that requires process performance be assessed and understood prior to making changes. Measurement and statistical analysis is also used to evaluate the effects of changes to the system. • Relies on people’s knowledge. Most process information does not reside in a database. Rather, information about processes is in the minds of those who do the work—the process owners. It is not just individual knowledge that is important but the collective knowledge of all those involved with the process. The knowledge of internal customers, patients, and suppliers is also valuable in understanding and improving processes. • Uses quantitative methods. The term quantitative methods refers to statistical and other graphical tools that summarize data in a structured way. These methods help in the identification, understanding, and control of factors related to performance. • Encourages people to identify common and special causes of performance problems. Common causes are sources of variation due to the system itself or the way the system is managed. Special causes are sources of variation due to isolated abnormalities or exceptional occurrences in the system. Actions taken on special causes can lead to immediate results, but actions on common causes can generate the greatest and most lasting benefits. • Helps your department be proactive. By anticipating and preventing poor performance, the department’s overall effectiveness is improved and limited resources are used efficiently. Your department should also be able to use the improvement model in conjunction with strategic plans to identify and respond to new requirements. • Is cyclical. Status quo is not good enough. Changes in strategic goals, resources, and operational constraints require HIM departments to continually seek new and better ways to achieve their objectives. The process improvement model should support ongoing monitoring of performance and use of new knowledge to address emerging needs. The concepts of continuous improvement have become commonplace in many healthcare organizations. Yet the process improvement techniques used in high-performing organizations have not found their way into all HIM departments. Many of the tools and techniques employed in improvement models such as Kaizen, RCI, Six Sigma, and Lean can be applied in HIM services to make them better managed, more predictable, and better controlled. Through the acquisition of quantitative information and the use of graphical and statistical analysis tools, HIM processes can be improved—and those improvements can be sustained. — Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of Leading Your Health Care Organization to Excellence, a partner in Brown-Spath & Associates (www.brownspath.com), and an assistant professor in the department of health services administration at the University of Alabama in Birmingham. Reference
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