3. Frontline Improvement Methods

MODULE 10 | Section 3 of 11

Frontline Improvement Methods

IMPROVEMENT METHODOLOGIES

Think about the problem you identified or one you read about in the previous section.

      • How would you solve it?
      • Where would you begin?
      • How would you implement your solution, and how would you verify that it’s having the impact that you intended?

Throughout this module, you will learn how interventions are planned, implemented, and improved.

There are a number of process improvement methodologies that are used in health care. A few of the most common are described below. Many institutions will primarily use one of these models (e.g., lean) to structure their institution-wide initiatives in order to create a common language and structure for everybody in the health system. Others borrow concepts from each of the below to create a customized version that works for their local health care system.

In this section, we will look at three major improvement methodologies commonly seen in health care: Lean, the Institute for Healthcare Improvement Model, and Six Sigma.

First, there are a few things all successful improvement methodologies have in common:

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Using clear and measurable goals

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Following data over time to guide decision-making and monitor improvement
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Tracking well-defined metrics
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Involving those on the frontline of care in the change process

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Developing a culture of continuous improvement1

LEAN

Grown originally from the automobile production industry, Lean is an improvement methodology that focuses on improving quality through the consistent removal of waste from a system1. Recall from module 1 that approximately a third of health care is considered waste – that is, it does not make people healthier. Thus, in health care there is a lot of waste to tackle!


TOP CONTRIBUTORS TO HEALTH CARE WASTE

There are multiple contributors to health care waste. Select each of the categories of waste (as defined by the Institute of Medicine) to find out more about them.

But even in a low-waste environment, Lean principles remain useful in that they aim to increase efficiency while maximizing value received for effort expended in a process.

There are dozens of books and articles you can read about Lean in a variety of settings, including health care. The Care Redesign Case at the end of this module will focus on how a health system, Virginia Mason Medical Center in Seattle, Washington, implemented Lean to transform their care processes. But before we get there, let’s take a brief fly-by of a few key Lean concepts.

THERE ARE 5 KEY PRINCIPLES OF THE LEAN IMPROVEMENT MODEL

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THERE ARE 5 KEY PRINCIPLES OF THE LEAN IMPROVEMENT MODEL

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GOING TO GEMBA

‘Gemba’ is a Japanese term that means, “the actual place.” As a Lean concept, it refers to the place where value is created. It is always important to go to Gemba — to go to the place work is done — so as to understand the process. Oftentimes interventions or project plans are designed sitting around a conference table, but this nearly always lacks the context and insights from the work environment that are critical to actual success.

 

Read more about going to Gemba in health care here.

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“In healthcare…waste is disrespectful to our patients because it asks them to endure a process with no value”

Patty Gabow, MD
Now retired after 20 years as CEO of Denver Health and Hospital Authority (DHHA)

INSTITUTE FOR HEALTHCARE IMPROVEMENT MODEL

The Institute for Healthcare Improvement (IHI) is a worldwide leader in health care quality training and innovation. The IHI improvement model is a straightforward approach to improvement with the Plan-Do-Study-Act (PDSA) cycle at its heart.1 It focuses on developing a goal and quality measures, and includes three key questions that should be asked throughout iterative cycles of continuous improvement to guide strategy and develop ongoing action plans.

MODEL FOR IMPROVEMENT

What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
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A key to this model is the concept of testing small-scale interventions and changes. The effect of these small changes should be measured and the action plan adjusted based on the results.

Three actions you might take based on the results are sometimes referred to the Three A’s:

ADOPT

ADAPT

ABANDON

 

We will cover the PDSA cycle in more detail in the following section.

Visit IHI’s Open School for more valuable information

SIX SIGMA

The Six Sigma improvement model, like Lean, has its roots in industrial manufacturing. Also similar to lean, the essential goal of Six Sigma is to eliminate defects and waste, thereby improving quality and efficiency by streamlining and improving all business processes.1The name Six Sigma comes from the concept of Statistical Process Control charts and the normal curve where sigma lines are plotted to indicate the expected spread of data. Sigma, or standard deviation, is a measure of the spread of data away from the mean or center line shown below. It is very rare, just like a coin flip being heads with 6/6 tosses, for data from any process to be outside of 3 sigma above or below the mean. In fact 99.73% of data will fall within these 6 sigma, hence the name of this improvement model. We will revisit the concept of sigma in a discussion of statistical process control charts later in this module.
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Similar to the PDSA approach, Six Sigma uses the DMAIC (Define, Measure, Analyze, Improve, Control) Methodology as a roadmap for process improvement. This is a very data-driven method that first analyzes current processes and outcomes in order to develop a baseline to understand the current system and measure the impact of the improved process once implemented.

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It is not necessarily important which improvement model you or your organization chooses to use; the critical thing is that you use an improvement model to guide your work. We will mostly focus this module on the IHI Model for Improvement and some selected Lean tools.

Learn More

WEBSITE
Find additional information about DMAIC and tools for using them at this site! DMAIC Tools: Process Improvement Tools and Templates website.
WEBSITE
Explore this IHI page on Model for Improvement for information on PDSA and white papers on the model’s application.
Institute for Healthcare Improvement website.

ARTICLE

Read this article on the application of six sigma to improve processes at a hospital in Milwaukee, WI.
Buck, C. Research article from Froedtert Memorial Lutheran Hospital.

REFERENCES

  1. 1-Agency for Healthcare Research and Quality. Section 4: ways to approach the quality improvement process. July, 2017

 

  1. 2-  Implementing Value-Based Initiatives: A New Challenge for Clinicians and Healthcare Systems. In: Moriates C, Arora V, Shah N. eds. Understanding Value-Based Healthcare New York, NY: McGraw-Hill. Accessed August 28, 2018.

 

  1. 3-Silver SA, Harel Z, McQuillan R, et al. How to begin a quality improvement projectClin J Am Soc Nephro. 2016;11(5):893-900.

 

  1. 4-Institute for Healthcare Improvement. Quality improvement essentials toolkit. IHI website. 2018.

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