Here's a q& a with the co-authors of the recently published "Performance Improvement for Healthcare - Leading Change with Lean, Six Sigma and Constraints Management."
Read on and lean!
q1. Can you introduce yourselves? What is your TOC background?
Baha Inozu: When I was in academia, my applied research mainly focused on reliability and maintenance management. I was exposed to Six Sigma first at a maintenance conference and had an opportunity to apply it initially to the dry-docking of ships. Then the U.S. Navy provided a research grant to my team at University of New Orleans to pioneer Lean and Six Sigma integration in shipbuilding at Northrop Grumman Ship Systems. The success of that project gave birth to NOVACES, which was founded by the project’s researchers. Next, we were invited to the core contractor team of the Enterprise AIRSpeed project to truly integrate TOC with Lean Six Sigma in the largest supply chain network in the world: the U.S. Naval Aviation Enterprise. The synergy between the methodologies was even more apparent than the differences. Subsequently, we had the opportunity to adopt and apply the integrated approach, first to Navy hospitals and clinics, and then to other health systems worldwide. Our passion to improve healthcare performance brought us together to write this book. I actually won the conference lottery to get my TOC Jonah training during the TOC World conference in 2006. That training fundamentally changed my perspective. As I started working on the AIRSpeed project with our team, I got exposed to the supply chain solutions of TOC. Later, I started learning Critical Chain Project Management and now I participate in its applications for aircraft modification design projects along with Dynamic Replenishment implementations for commercial Aviation MROs.
Dan Chauncey: I have been directly involved in the implementation of quality since the heydays of TQM in the mid-1980s. My early application was using both the TQM team-based, facilitated approach and standard industrial engineering methods. As I transitioned into Six Sigma, I realized how a truly structured application of statistical tools, along with constant subject matter expert team input was truly powerful. Then came Lean. I could not believe that we would just "throw out" the use of inferential statistics in favor of the pursuit of "continuous flow" (oversimplified, I know). Then I realized the synergies and that you don't always need to apply heavy analysis. That worked fine for several years until I began to understand the potential of Theory of Constraints. Once again, I had to break through methodological paradigms and realize that my toolbox had room for even more. In addition to enhancing some of the concepts from Lean (through some of the supply chain solutions), TOC provides a way to focus efforts and see the organization differently. I believe that the book title "Learning to See" by Rother, et.al., is even better suited for TOC.
q2. Why this book? It's hard work writing a book ... why did you feel compelled to write THIS book?
Each of the book’s authors has been a patient more than once. We have observed the vast numbers of inefficiencies, bottlenecks, and mistakes and the huge amounts of waste as both patients and practitioners. Every doctor, nurse, technician, administrator, and staff member is a patient at some point. Every year when health insurance renewal time comes, we all continue to be frustrated with rising costs and diminishing benefits, from individual consumers to small business owners and large corporations. There are few issues that touch so many lives as the importance of quality healthcare.
q3. What problems will reading the book solve?
Healthcare professionals already know that performance improvement doesn’t just mean working harder. The question they have is: “How can my healthcare organization work smarter?” This book answers the question, “how?” – it requires systems thinking and an integrated approach; by applying commonsense breakthrough solutions to manage bottlenecks, eliminate waste, reduce errors, and contain costs in their healthcare organizations.But these same readers have already answered this question. They have been on that merry-go-round. This is not their first time at the rodeo. They have tried the flavors of the month. It takes little experience to know that many performance-improvement deployments tend to plateau— or at least reach the point of diminishing returns. Yet we know intuitively that there is so much untapped potential yet to be realized. We need a mechanism to know the area of organization to focus on so that the biggest gains can be achieved. Performance Improvement for Healthcare provides that focusing mechanism by integrating a mature, powerful methodology proven in private industry for decades, called Constraints Management. This book demonstrates how to revitalize performance-improvement efforts and replace diminishing returns with flourishing growth.
q4. What's your favorite TOC story (from the book, or otherwise)?
A hospital CEO once said: “Hospitals are a business; they are in the business of caring for patients and families.” At the end of the day, performance improvement in healthcare is all about doing what is right for one patient while ensuring that the organization has the resources to continue doing what is right for the next patient. If healthcare is an intensely competitive business climate, how do we resolve the conflict between improving the quality of patient care and reducing costs?
There is no conflict.
When bed-bound patients suffer from pressure ulcers due to not being turned in a timely manner, or a patient falls – poor quality and cost are synonymous.
Just a few years ago, the Millennium Research Group cited medical errors as the fifth-leading cause of death in the US.
Hospital-acquired infections have been identified as a leading cause of death as well.The costs of poor quality are becoming increasingly clear.
And it’s not just patients and healthcare providers who are catching on. More and more, what are seen as preventable problems are not being reimbursed by Medicare or insurance companies.
By applying principles to control variation and manage bottlenecks, which have been proven in industry for decades, we can see that the perceived conflict between cost and quality is actually a mirage. Focused, aligned, patient-centric care does not compromise costs. The reality is that it actually improves the bottom line, not drain costs. The management problems healthcare is struggling with have already been solved and the solutions are in the public domain.
Why haven’t these mature advancements been applied to healthcare?Although we have been getting better, healthcare, as an industry, is especially resistant to change.The Institute of Medicine noted a 17-year lag between the publication of research and its impact on patient care. This delay in applying evidence-based best practices to service delivery isn’t just unimaginable in other industries – in other industries, they’d go out of business.
Healthcare doesn’t have to be this way.We wrote this book to show that there is a better way – and how to get there.
q5. Pick your own question and answer it ...
What is a robust deployment approach?
A robust approach for deploying performance improvement is applicable to any organization regardless of its current degree of deployment progress or success. Three ways to categorize this progress are Greenfield, Revitalization and New Heights.
Every organization must decide what its purpose or goal is in deploying performance improvement. For some, it is the absence of a structured approach to performance improvement altogether. Others have an approach in place and desire to either revitalize it or take it to the next level. The most obvious level of maturity is the organization with virtually no structured approach in place. In such organizations, this is referred to as a Greenfield deployment, and these organizations may have been realizing some degree of improvement, but it was not due to any organized or focused level of effort.
Some organizations have initiated actions to institutionalize their performance-improvement program but seem unable to gain any real traction. These false starts tend to create disenchantment with a focused performance-improvement program. Both organizational leadership and staff begin to believe that they were better off with whatever method or approach they were using prior to the current deployment. This is common in healthcare organizations, where many versions of quality improvement are either currently in place or have been in place over the years. Not only are several approaches being used, but they also tend to be disparate in organizational placement and level, splitting intent and focus. These organizations need to revitalize their performance-improvement efforts.
Another organizational scenario is one that has been successful with performance-improvement efforts in the past, and now leadership wants to take the program to the next level—or new heights. In many ways, deployment in this type of organization is the most difficult. People become comfortable with the status quo—especially if it is meeting expectations.
While these descriptions alluded to organization-wide deployments, they also can be applied to division or department levels as well. In much the same way that an efficacious performance-improvement program must be robust across various deployment maturity levels, it also must be scalable to organizational size or even levels within an organization. While sustainment across an entire system historically has proven difficult, sound performance-improvement practices can be deployed within a single department or division—radiology, for example.
In some cases, this limited deployment is applied as a pilot for a broader deployment in the future. While this method has worked in many organizations, it should be pursued with caution owing to the high degree of interdependency between organizational entities within healthcare.