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Jay Arthur—The KnowWare Man

Health Care

Why Healthcare Isn’t Getting Better

Despite years of lean Six Sigma training, we aren’t seeing results

Published: Thursday, November 29, 2012 - 10:17

The United States spends $2.5 trillion for healthcare. Healthcare spending is expected to reach $4.5 trillion by the end of the decade. With Obamacare becoming a reality, we need to find a way cut the cost of healthcare to help pay for these increasing costs. The Institute of Medicine (IOM) estimates that $750 billion of current spending is for unnecessary testing, waste, and rework. That’s about a third of total healthcare spending.

Sadly, there’s no sign of improvement. Consider the following:
• Wait times in U.S. emergency departments (ED) rose from 46 minutes to 58 minutes from 2009 to 2012 (CapSite's "2012 U.S. Patient Flow Study"). The average time between a patient entering the ED and seeing a physician is 56 minutes. (Centers for Disease Control and Prevention, 2010)
• ED length of stay (LOS) remains at four hours, unchanged for a decade. (Press Ganey, Emergency Department Pulse Report, 2010)
• One in six patients suffers a complication related to their treatment, not their disease, according to Don Berwick, M.D., speaking to Money magazine ("Medicare in America: 'It has to get better'," Amanda Gengler, Money, November 29, 2011)
• The 1999 To Err is Human IOM report startled the nation by reporting that 99,000 hospital patients die unnecessarily. Since then, healthcare has become much better at tracking preventable deaths. Now we know that 99,000 die each year of preventable hospital acquired infections (HAIs). 150,000 a year die from surgical complications, and another 150,000 from medication errors, and that’s just in hospitals. These totals do not include other healthcare venues. (Atul Gawande M.D., The Checklist Manifesto, Henry Holt, New York, 2009)

Add it up and you will see that more than 400,000 patients a year that die from complications caused by their treatment, not their disease.

The 2008 National Healthcare Quality Report (AHRQ, 2009) notes that patient safety has actually been getting worse instead of better. In "One Decade after To Err is Human" in Patient Safety & Healthcare Quality (Carolyn M. Clancy, MD, September/October 2009), Dr. Clancy writes: "AHRQ’s late director, John Eisenberg, M.D., likened the problem of medical errors to an epidemic."

Note that the title, To Err is Human, presupposes that the root cause of the problem is people, not the processes and systems of healthcare. This violates one of Deming’s points that 99 percent of problems are system problems, not people problems. It should have been called: To Err is System.

The conclusion is that healthcare is sick and it isn’t getting better. Aside from a handful of hospitals and doctors like Peter Pronovost and Atul Gawande charging forward on improvement efforts, healthcare is admiring the problem and hoping it will go away. It will not and we cannot afford to wait.

Lean Six Sigma training isn’t working

In spite of decades of process improvement and lean Six Sigma training, there’s almost no sign of its use. Sure, the Joint Commission forces hospitals to use control charts to track key measures, but that’s where it seems to stop.

How do I know it stops there? Here’s my metric: Every December, 6,000 doctors and nurses meet at the Institute for Healthcare Improvement conference in Orlando. Thousands more meet in state and National Healthcare Association for Quality (NAHQ) meetings. 8,000 nurses gather at the Magnet Conference. I exhibit at the conference to promote my QI Macros software.

Teams from all over the country bring posters (i.e., storyboards) of their improvement projects. After years of exhibiting and looking at hundreds and hundreds of improvement projects displayed at these conferences, I can tell they aren’t using the tools of quality. These storyboards are mainly text with a chart or two. What kind of charts do they use? Mainly bar and line charts. At the 2012 Magnet Conference I created a check sheet of tool usage:

Where are the control charts, Pareto charts, histograms and fishbone diagrams to illustrate the improvement? Where are the before-and-after control charts to verify improvement? Where are the control plans to sustain the improvement? Where are the before-and-after value stream maps and spaghetti diagrams?

Unfortunately, most of these improvements are doomed to erode. What was fixed one year will become broken again the next.

What’s wrong with this picture?

Obviously, the lean Six Sigma training and TQM training that preceded it couldn’t have been very effective or we would see more of the tools of quality in these improvement storyboards. Maybe these pracitioners were trained in these tools, but didn’t use that training on an improvement project immediately and forgot most of what they learned. Maybe nobody understands the “C” in DMAIC (define, measure, analyze, improve, control). Certainly these posters demonstrate no method for monitoring and sustaining improvement Maybe people were trained, but the IT department decided to scrimp on Six Sigma software so no team has the tools it needs to draw control charts, Pareto charts, histograms, and so on.


It doesn’t matter how you slice it, healthcare is sick and it isn’t getting better. If thousands of people were dying every week from food poisoning or airplane crashes, the public would be screaming for someone to do something. But because healthcare-related deaths strike here and there, in one hospital this week and a different one next week, seemingly without a pattern, it’s hard to scramble a response.

The current approach to lean Six Sigma in healthcare isn’t effective. Despite weeks of Green Belt and Black Belt training and widespread deployment, lean Six Sigma simply hasn’t made a dent in healthcare quality.


My approach to lean Six Sigma in healthcare has taken a different path.

I believe that if people don’t start using the tools on projects they care about immediately, right in the classroom, they just won’t get it or retain it. If, however, I can get them to draw a value stream map or spaghetti diagram of their ED, nursing unit, lab, imaging, or other facility, they immediately find several ways to make it better.

When I get them drawing control charts and Pareto charts of their data in class using the QI Macros, they immediately go to their data and start drawing other charts and doing more analysis.

I do all of this in a day: Lean in the morning, Six Sigma in the afternoon. I teach what I call the “Magnificent Seven” tools of Lean Six Sigma. I’ve put this training up on YouTube at www.lssmb.com.

Do participants leave knowing everything in the Green Belt or Black Belt body of knowledge (BOK)? No. From a lean perspective I think that most of the BOK is a form of overproduction. We teach them things they don’t need to know to solve problems they won’t face for many years. This causes confusion, not action or improvement.

Healthcare isn’t manufacturing; it’s a service industry. It doesn’t need to know all of the tools necessary to make widgets reliably. Healthcare only needs the Magnificent Seven tools. Everything else is waste.

Like healthcare, the lean Six Sigma community doesn’t want to change how it does things to respond to the new, high-speed environment of change we live in. Many people in healthcare complain that their Six Sigma training used manufacturing examples, not healthcare ones. Frankly, I think that should be considered malpractice.

Many of the Green Belts and Black Belts I talk to have never done an improvement project! We don’t need more Green Belts and Black Belts; we need more “Money Belts”—people who can use the tools of quality to save time and cost while boosting productivity and profitability. Nowhere is this need more imperative than in healthcare.


About The Author

Jay Arthur—The KnowWare Man’s picture

Jay Arthur—The KnowWare Man

Jay Arthur, speaker, trainer, founder of KnowWare International Inc., and developer of QI Macros for Excel, understands how to pinpoint areas for improvement in processes, people, and technology. He uses data to pinpoint broken processes and helps teams understand their communication styles and restore broken connections. Arthur is the author of Lean Six Sigma for Hospitals (McGraw-Hill, 2011), and Lean Six Sigma Demystified (McGraw-Hill, 2010), and QI Macros SPC Software for Excel. He has 30 years experience developing software. Located in Denver, KnowWare International helps service and manufacturing businesses use lean Six Sigma tools to drive dramatic performance improvements.


Do we really need other Heroes?

Or do we need just honest, reliable workers? And the tops - leaders and managers - at an equal level? It's true: millions are spent in "tools" like Six Sigma - or, more realistically "wasted" in such "toys". What's really worrying is that key social issues like Healthcare and Education are worldwide considered just as the ancient Romans' "cloaca maxima". Thank you.

Lean isn't just Tools...

Lean is proving successful, I should clarify, in the organizations that realize Lean is a management system, a philosophy, a way of thinking, etc.

I agree that a new way of thinking is necessary... building on the lessons of Dr. Deming, of Lean/TPS (Deming was a huge influence on Toyota)...

See ThedaCare, Virginia Mason, Seattle Children's, St. Elisabeth Hospital (the Netherlands) and many others that have shared their new thinking via Lean... the hospitals that are just copying industrial tools will struggle.

Stop trying to make Healthcare into Toyota

If there is one disease we have in the US it is the mass production mindset that Deming warned us about long ago. Lean helps us copy the industrial tools of Toyota while hospitals have different problems. Six Sigma gives more analysis when we are already over-analyzing and complicating our systems. We have a huge thinking problem in this country . . . a bankruptcy if you will. Until we address this problem we have no where to go but to seek the bottom.

Sick Sigma

Six Sigma is sicker than healthcare.  http://www.qualitydigest.com/inside/six-sigma-article/sick-sigma

Quality might have half a chance in health care if people got the basics right.  Teaching the Six Sigma nonsense is a guaranteed way to fail.  It's time to get back to Deming.

Lots of Lean Success

There are many pockets of Lean Healthcare success in the U.S. and around the world. We need more consistent application of Lean methods... not just in those pockets.

Most of these initiatives have nothing to do with Six Sigma, actually.