Article Revised: March 26, 2019
Apparently there are still questions about whether or not a process improvement methodology like lean or Six Sigma can work in healthcare. I find this astonishing and disingenuous. The only real requirement for deploying any process improvement is whether or not there is a process that is done more than once. Healthcare at any respectably sized organization involves thousands of patients, procedures, images, admissions, discharges, transfers, prescriptions, physician orders, medication administration, IV line insertions, laboratory tests. Need I go on?
Every time one of these things take place there are many ways they can go wrong. Patients can be misdiagnosed, emergencies can take too long to attend do, images can be poorly done or misinterpreted, admissions can be too time consuming and expensive, discharges can take place too early or without adequate instruction, transfers can injure patients, prescriptions can be issued in error or filled in error, physician’s orders can be incorrect or incorrectly interpreted or incorrectly followed, medications can be incorrectly administered, IV lines can become infected, lab tests can be done incorrectly or cost too much or take too long to do.
So, we have a very long list of clinical and non-clinical healthcare processes. For every process we have a very long list of things that can go wrong with the process, and an equally long list of ways in which the process can be done better.
Over 20 years ago the National Demonstration Project on Quality Improvement in Healthcare examined the applicability of quality methods to healthcare issues. They concluded
What is truly unique about the field of quality control is not its tools, but its ethos–the set of attitudes that it brings to quality problems.
Here’s a short list of what is included in this ethos
- Prevention is preferable to detection.
- Focus on the system, not the individual
- The customer is central
- Variation is endemic. Different types of variation require different types of responses
- Quality should be defined broadly. It is not simply quality of care that matters, but also quality of service, amenities, reliabilitiy–all of the aspects of the healthcare encounter.
The NDP proved that the quality approach (aka Six Sigma and Lean) had value to the healthcare community, but there has never been widespread acceptance. I believe that the root cause of this is a system of perverse economic incentives that makes poor quality pay. A c-section poses higher risk to the mother and the baby. But whether or not a c-section is needed is a judgment call. If one is performed it costs several thousand additional dollars. Those dollars are revenue to the hospital and income to a physician, an anesthesiologist and other professionals and care providers. These are simple facts that can’t help but influence the decision-making process. When Six Sigma or Lean come along and promise to drastically reduce problems and system failures, it is only natural that the people involved consider the impact on their top and bottom lines. Until this situation changes, process excellence will be a tough sell in healthcare.