Variation in Health Care Processes
One of the key concepts that Dr. Deming (and others) introduced to health care, from industry, was the concept of the variation in key processes.
In addition, one of the main factors that has been identified in the review of patient safety incidents; the rising cost of health care; and the increase in patient complaints is the variation in how we deliver care and service to our patients.
Important: Minimum 200 words required. Reference material about “variation” attached. Thank you.
Week One, Session Two, Lecture 2
Chapters 4 – Understanding Variation, Tools, and Data Sources of CQI in Health Care
Chapter 5 – Lean and 6 Sigma Management: Building a Foundation for Optimal Patient Care Using Patient Flow Physics
Welcome to Session Two.
In session one, we covered the evolution of CQI and the key concepts as they have been adopted from industry. We also covered a review of where health care is today related to the implementation of these key concepts and tools and some strategies to understand and further the diffusion of these concepts in health care.
We will now begin to drill down on the core principles of CQI including the importance of variation and the emergence of Lean and 6 Sigma in the health care management tool kit.
You will note that I have given you the information related to the Week Two paper in Blackboard for Week Two. Exploring a key influencer from the past or present, their contributions and how they affected (or are affecting) the evolution of CQI in health care will further your understanding of the materials that we are studying.
Introduction
So, as we move forward into Chapters 4 and 5, let’s review the summarization of Dr. Deming’s fourteen points into our “three-legged stool”. One of the key foundation posts of our stool is understanding work as a process and a system of processes in order to assure that our CQI efforts are on target – we will be exploring this further in these chapters.
Before we can make improvements to care and service, we must understand how the work we do is structured, how we can measure its effectiveness and how we can use data and CQI tools to continuously improve it.
Understanding our work processes and utilizing data to evaluate their effectiveness before and after our improvement efforts is critical to insure we are addressing the right things to improve. Health care is known for being “data-rich and information-poor”. We have learned that unless the data is utilized appropriately and translated into information it is not necessarily useful to us on our path to improvement.
Because of the history of how our health care systems have grown and especially because of the focus on the autonomy of providers in their training and practice, historically, each provider and organization have done things in their own way.
From studies conducted early in the 2000s, we have learned there has been a wide variation in practice leading to different mortality rates for the same procedures, as well as different costs and patient outcomes depending on the geographic area of the country. These studies triggered key efforts by regulators, politicians and researchers to begin to collect data and benchmark these procedures in order to understand this wide variation.
The Role of Variation in CQI
As we have learned in reviewing the evolution of CQI from industry, one of the core principles in CQI has been the existence of variation in how work is done and understanding why this variation exists.
We know that variation exists naturally in all processes, but before we can understand our key work processes (for care and service) we must be able to measure them and understand the reasons for the variation.
What is Variation?
Variation is defined as the extent to which a process differs from the norm. Let’s say that we have three employees who live in the same apartment building and work at the same office. If we measure the time it takes for each to get to work each day, even though the distance is the same, we find that there is variation in the time it takes them to get to work.
Just as this example shows, we know we have variation in processes and outcomes, naturally in organizations, and in the practice of individual providers. However, why does the U.S. rank 37th overall in the world when we pay the most of health care per patient? Why do chronically ill patients only receive 20 – 30% of the care they need based on studies?
The Nature of Variation
So, although variation exists in all processes naturally – some variation is acceptable based on the individual needs of the patient, and other variation is not acceptable – why are the outcomes for the same procedure, from a quality and cost standpoint, different depending on where you live?
There are two general categories of variation, first described by Deming (1986),
special and common.
·
Special causes of process variation
: unnecessary variation associated with specific material(s), machine(s), or individual(s) (i.e. In our “getting to work” example – Traffic accident!)
·
Common cause variation
is the inherent variance in the process that is a result of how the process is performed
· It is also referred to as systemic or internal variation
· Can only be addressed by those working directly with the process (i.e. The time it takes to get out of the house!)
· Responsibility of management to correct, as management is responsible for correcting and preventing system problems
We must understand the nature of variation, whether is it from a special cause, or if it is inherent in the way a process is designed, before we can make efforts to improve it. Understanding, through measurement, if a process has variation; what the nature of the variation is; and, if it is acceptable or unacceptable can lead us to the right action to take in improving outcomes of the process overall.
Measurement and Statistical Analysis
Using CQI tools and data to understand the steps in a process, the capability of the process (you can not get to work in 20 minutes if you live 50 miles away!) and what are the key requirements of the process according to its key customers; are all critical elements in designing an improvement effort.
CQI Tools
CQI and statistical tools such as flow diagramming to understand the steps in a process and run charts, to identify variation and the nature of the variation are examples of the use of the tools in the CQI tool kit.
The model for improvement that we have learned, PDSA, along with the CQI tools provide a consistent approach for measuring and understanding our key care and services processes and how to improve them
A summary of the key tools is including in Chapter Four and we will be delving into a number of these as we move through other chapters.
Sources of Data for CQI
The data that we use in the CQI process comes from two sources: (1) Primary data – collected for a specific purpose of measuring performance and improvement, usually collected from data related to ongoing care of patients; and (2) Secondary date – Such as data from claims and the electronic health record (EHR). The data sampling methods differ depending on the purpose of the data collection.
Conclusions
Understanding the major role that variation in care and services has on the outcomes of the patient, along with the importance of measure and use of the CQI tool kit are the critical first steps in the CQI process.
Chapter 5 – Lean and Sis Sigma Management: Building a Foundation for Patient Care Using Patient Flow Physics
“The ultimate arrogance is to change the way people work, without changing the way we manage them.” John Toussaint
Introduction
We have been addressing the evolution of CQI, first in industry, and then in health care.
Although the diffusion of CQI in health care has been a challenging process because of the complexity, history and cost; the CQI process has continued to evolve with great applications for health care, now and in the future.
We will review the next steps that this evolution has taken with CQI and its tools in order to learn how to understand and apply these methodologies to the future of CQI in health care. The topic of Lean Six Sigma Management (LSM) is broad, so we will highlight key concepts through this lecture and the slide presentation presented.
Six Sigma, developed by Motorola, based on the Japanese model, takes the next steps in utilizing the statistical tools to identify and reduce variation in processes to continue to improve quality and safety in health care.
Lean Management, developed by Toyota, emphasizes the elimination of waste in health care processes to reduce cost and improve quality and safety outcomes.
Six Sigma
After studying the quality methods in Japan, Motorola created a standard process utilizing the tools and statistical process to: reduce defects 10-fold every two years; and reduce cycle time of all core processes by 50% within two years. Keep in mind that the key processes in industry are less complex than those of health care.
The core focus of Motorola was that variation can lead to greater defects/error rates and processes could not be shortened without eliminating unnecessary, non-value-added steps.
Their key concepts included: the customer defines what value is; every process should be evaluated in order to eliminate wasted steps; organizations should work continuously to reduce steps, time, cost and information (data) needed to serve the customer.
Lean Management
Toyota organized their approach focusing on: the types of waste – “muda”; the overburdening of staff and equipment – “muri”; and the unevenness of process flow – “mura”.
Muda – focuses on elimination of the waste in seven resources: transportation, inventory, motion during production, waiting times, over processing, over production and defects. These translate to health care as: rework, wasted inventory, excess waiting time, lost time, errors, extra work due to poor processes or outdated procedures, and west from the transporting of patients.
Muri – exists when the staff and physicians feel overwhelmed with the level and efforts required to provide and document care, address regulatory requirements, as well as required meeting and support process not associated with direct patient care.
Muri – waste due to variation or unevenness in process workflow; and batching work such as reading radiology results and morning blood draws.
Major functions in Lean organizations include: maintain or controlling existing processes; improving existing processes and an emphasis on continuous improvement, staff development, belief systems (culture) and change management.
Implementation
The implementation of LSM takes leadership commitment, the building of support functions and a culture of excellence, over time – it cannot be accomplished overnight. Lean and Sis Sigma should be fused because: Lean efforts alone cannot bring a process under control; and Six Sigma alone cannot dramatically improve process speed or the elimination of waste.
The Toyota Production System argues that organizational culture can change through the inculcation of principles that they identify as The Four P Model. This includes (1) Problem-solving for continuous organizational learning and alignment; (2) People are respected, engaged and developed; (3) Processes are improved and stabilized based on customer defined value; and the (4) Philosophy has a long-term focus. These four principles provide a foundation for this work.
Leadership Best Practices
A number of best practices for leaders are presented that include leader stand practices; the use of visual controls, metrics for ongoing leadership review, leadership walk-arounds (GEMBA), and the use of huddle boards.
Key point: Organizations that focus on improving value-added activities can develop a strategic and competitive advantage.
Case Study Resources
Chapter Five presents an example of these tools and methods used in an effort to improve patient flow. This example presented in the Case Study: Applying LSS to Patient Flow in Community Hospital Emergency Department, and is especially relevant because data tells us that only a fraction of the time that patients spend in the health care process is directly associated with diagnosis and treatment – the rest is just waiting!
The example of the tools and methodology include: incorporating process and flow data; applying factory physics principles to better manage volume; scheduling; and the improvement of patient satisfaction.
Using these tools and methodology help create strategies to: understand the patterns of demand (based on data); standardize care for typical patients to reduce variation and unevenness in the patient flow; utilize the best practices from high reliability organization in their standardization using evidenced- based, best practices; the advanced use of population data; the creation of buffers for high impact time frames; and improving overall patient care design efforts.
The case study provides excellent examples of the use of statistical tools for this example and are also presented in the power point presentation attached here.
Conclusion
There are great examples of health care organizations that are moving forward with the use of these tools in their improvement efforts. The focus of your final project for the class with be the identification of such an organization with a review of their methods and results and lessons learned. This is outlined in Week Four in Blackboard.
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