Companies in the healthcare industry should regularly ask themselves the question, “Should we spend time and resources improving existing products and services or innovating new ones?” The answer to that question depends on several factors.

Traditional Quality Programs Aim to Improve Existing Products

Traditional quality programs, such as Lean and Six Sigma, focus efforts on improving existing products and services. For instance, the established process improvement approach for Six Sigma is called DMAIC (Define, Measure, Analyze, Improve and Control). After project sponsors define an improvement opportunity, a project improvement team measures the current state, analyzes for root cause, improves the existing process by eliminating the root cause and then controls the improvement by ensuring old ways do not creep back into the improved process, product or service.

Since the late 1980s, when Motorola developed the methodology, this traditional approach has been successful for many companies. The same can be said for Lean after Toyota developed the Toyota Production System.

However, even with the plethora of success stories, traditional quality programs can sometimes come at a devastating price, because improving an existing product or service assumes the status quo will continue. As a result, although it is in a “new and improved” state, it is still the same product or service. What happens when the market shifts and no longer desires that particular product or service?

Improve or Innovate Your Healthcare Product or Service?

Investing resources on improving a product or service that is at the end of its life is akin to improving mechanical typewriters when the market was demanding word processors. This mindset can be even more damaging because it  draws attention away from an imminent external paradigm shift and focuses on an internal self-fulfilling optimism for the dying product, which results in missed opportunities and eventual demise.

In the healthcare industry, where the speed of change is equal to, if not greater than many technology hypergrowth markets, organizations must constantly review their products and services before spending time or resources on improvement.

There are certain situations in which continuous improvement can further enhance customer satisfaction and loyalty, resulting in even higher demand. But for most organizations, a different approach is needed; one that is geared toward innovation.

Phytel’s Approach to Innovation

Fortunately, an approach to innovation does exist, referred to as Design for Six Sigma. There are several different Six Sigma designs a company could use, but the method depends on the type of product of service provided. Here at Phytel we use an innovative methodology termed DMADV, an approach especially useful for innovating software and service processes.

5 Steps to Innovate Healthcare Products and Services

Define and Measure

After the need for innovation is identified (Define), the project team begins collecting the Voice of the Customer (Measure). During this phase, several concepts are deployed, including industry-standard tool called a QFD (Quality Functional Deployment), which prioritizes and maps our customers desires to delivery options.

These customer desires are referred to as CTQs (Critical-to-Quality features or services). CTQs in the healthcare industry could come from clients, patients, quality organizations (such as the NCQA) or regulatory agencies. In the QFD, the relationship between each CTQ and how to deliver is measured, allowing subject matter experts to determine which features to develop in the new product or service.

Analyze

Once the CTQs and the approach to deliver them are defined, the project team outlines, at a very high level, alternative solutions (Analyze). Additional tools, such as a Pugh Matrix are used to compare the various alternative designs, often resulting in what is referred to as a Frankenstein model. The Frankenstein model takes the best of all the alternative solutions and combines them into one best approach.

Design

The design with the highest score, typically the Frankenstein design, would then transition into the detailed design phase (Design). During this stage, the high-level design is analyzed and broken down into a task-level structure than can be performed at an individual contributor level.

At this point, the design on paper is then translated into what is referred to as a Transfer Function. This is a mathematical representation of the design so that the performance of the design can be measured against the CTQs. Usually tweaks to the design occur to improve the likelihood of achieving the desired results. Once the design is structured, the team then determines what type of changes is needed to support the new product or service. Many times, technology changes, process changes and training are required to prepare the organization.

Verify

Finally, the product or service is piloted on a small scale in a beta environment to check for final tweaks and to gather measurement data on the results (Verify). During this final phase, the project team collects data from the pilot and ensures that the process to produce the new product or services is stabilized. Control Charts are often used to determine process stability, followed by a capability analysis to determine the probability of delivering against each CTQ. The new product or service is monitored throughout its lifecycle for continuous improvement. That is, until it is no longer in demand.

Conclusion

When should a company operating in the healthcare industry innovate rather than spend time and resources on improving existing products and services? Well, the answer to that question depends on the life stage of each product or service offered.

A Value Stream is an end-to-end process that flows horizontally through an organization in order to provide value to a client, patient or customer. Many organizations map processes vertically rather than horizontally focusing on a department over the entity that flows through the entire organization. In a horizontal process design, however, because the entity is what is mapped and not a facility or department, handoffs can be visualized and downstream affects identified.

How Many Value Streams Does Your Organization Have?

Many entities can flow through an organization, but only one entity can flow through a single Value Stream. For instance, a patient would represent the primary entity that flows through a medical practice’s or hospital’s core Value Stream, while a staff member, who also represents an entity flowing through a healthcare organization, flows through an entirely separate Value Stream.

Experience has shown that most organizations have between five and eight Value Streams that either directly or indirectly touch their constituents.

What Makes a Value Stream Map Effective?

For a Value Stream map to be effective, it is critical to determine the beginning and ending points of the end-to-end horizontal process. Identifying the beginning and ending of a Value Stream can easily become an area of great debate.

For example, many may feel that the patient Value Stream begins when a person enters the practice or hospital, whereas others may feel that the Value Stream begins through a healthcare branding campaign. Both are correct, but all must agree on which beginning point to use for the Value Stream. The same goes for the ending point. It is generally best to start the process at the very first point in which the entity is touched and then end at very last point.

Identifying Process Steps

Once the beginning and ending process steps are established, individual process steps must be identified in order of flow. These steps represent a noun and a verb combined to articulate a high level action that is necessary to deliver the entity through the process.

After the high level process steps are determined and aligned into the proper flow, the sub-process steps need to be identified for each high level process step. Again, it is critical that each sub-process step be aligned into its logical flow.  It is recommended that during the mapping exercise, the departmental groups performing each sub-process are named. This allows for a cross-functional visualization for the end-to-end Value Stream.

Defining Core Metrics

After the process is mapped, the core metrics for each Value Stream must be identified and measured. This will facilitate continuous improvement by monitoring and measuring the Value Stream against a patient-stated requirement.

Benefits

Some of the benefits in visualizing the path of an entity as it flows through an organization are:

• Staff members can see how their process directly or indirectly touches a patient.
• The effects upstream processes have on downstream processes become evident.
• When changes are made to an upstream process, it is much easier to model the expected downstream effect.
• When quality and process metrics fail to meet requirements, it is easier to determine the point at which the root cause occurred.
• Hand-offs between processes can be better managed. In many cases, the transition between handoffs is where both defects and delays occur.
• Each process step can be measured in terms of its impact on overall cycle-time.
• It can aid in identifying areas for quick improvement.

Conclusion

Horizontally Value Stream mapping how an entity moves end-to-end though an organization can offer many benefits beyond the traditional vertical way of thinking. This method encourages organizations to take a patient-centered focus in how it manages processes and measures success.

A recent consensus report by The Commonwealth Fund emphasizes the role of health IT in care coordination, while asserting that today’s information technology is inadequate to the purpose.

“Anchoring the electronic health record (EHR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises…Health IT requires new functional capabilities, such as multiple team member access and permissions, care management workflow support, integrated personal health records, registry functionalities, clinical decision support, measurement of quality and efficiency, and robust reporting.”

The bulk of the technologies required to achieve these goals are already available. Among the reasons they’re not being properly deployed in most cases are these:

• Electronic health records are not designed to do population health management or care coordination.
• Registries tend to be focused on patients with particular conditions, rather than entire populations.
• Care management workflow support is still a relatively new concept, but one that more and more groups are embracing.

Group practices that are trying to transform themselves also have to manage a variety of other issues, including cultural barriers to change, potential infrastructure issues, and limited reimbursement for non-visit and non-physician care.

Key Building Blocks

Technology tools are also being used to improve communications across care settings, especially during transitions of care. These range from traditional point-to-point interfaces to physician and patient web portals to secure electronic messaging. Even computer faxing has its place as the industry moves from paper to electronic documentation of care.

The automated stratification of patients into different risk categories is also important to groups seeking to do population health management. For example, UNC Healthcare uses a health risk assessment (HRA) survey to find out how sick each of its patients with diabetes is. Then it uses an advanced patient registry and evidence-based algorithms to drive team-based care for each of those patients, depending on the severity of his or her condition.

Many practices use electronic registries to supplement their EHRs. These registries compile lists of subpopulations that need particular kinds of preventive and chronic care, such as annual mammograms for women over 40 or HbA1c tests at particular intervals for diabetic patients. The continuously updated data in the registries comes from EHRs, practice management systems, or a combination of the two. Evidence-based clinical protocols, which can be customized by physician practices, trigger alerts in the registries. When a registry is linked to an outbound messaging system, patients are notified by automated telephone, e-mail or text messages to contact their physician for an appointment. Some registries can also send actionable data to care teams prior to patient visits.

Care Coordination Leverages IT

The overall lesson to be drawn from the efforts to improve care coordination will require the use of information technology. The identification of patients with particular conditions, health risk assessments, the ability to send care gap alerts to providers, the care management of chronically ill patients, tailored patient education, and persistent reminders to patients to get the care they need—all of these interventions require some degree of automation to be performed in a timely, consistent, cost-effective manner.

The recent advances in health IT and further developments in this vital field will continue to support and enhance care coordination as it expands across the spectrum of care. Assuming that payment methods support coordinated care, we can look forward to a proliferation of new IT tools that will help turn the dream of affordable, high-quality healthcare for all into a reality.

There has been a plethora of discussion in the healthcare industry, concerning the conflicts between Lean and ISO (or other healthcare quality certifications).

While many organizations are initiating Lean as a way to increase process efficiency through waste elimination, others are pursuing ISO certification as a way to ensure their services consistently meet and exceed their patient’s requirements.

Where Lean is embodied through employee empowerment, ISO appears to be embodied through command and control. As Lean seeks to eliminate nonvalue-added activities, ISO seems to add bureaucracy through increased documentation control.

Consequently then, how can a healthcare organization pursue both approaches when the two seem to be in such conflict with each other? As difficult as this may sound, the solution is actually very simple. Apply Lean thinking to the ISO deployment, and ISO thinking for Lean standardization and continual improvement.

Lean Core Concept

The core concept of Lean is to eliminate nonvalue-added activities in the core value streams. Any process step can be tested for value by asking three questions:

1.    Would patients in our community be willing to pay for it

AND

2.    It changes the service or offering

AND

3.    It is completed correctly the first time (quality, access and reliability)

ISO Core Concept

Whereas the core concept of ISO is to ensure the organization consistently delivers a quality service to the patients. Therefore, the two approaches work well together when employees and care teams are empowered to not initiate ISO with process steps that do not meet the Lean criteria, but rather remove them, and only control and continually improve the process steps that result in high patient experience of care.

Combining the Two Approaches

Through this approach, organizations can empower your staff to improve process efficiency while standardizing and controlling the most critical process activities within your value streams.

Jerry Green is Director of Quality Management at Phytel.

In the book, “Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience,” Virginia Mason Medical Center (VMMC) describes its Lean journey over the course of the last decade. One of Phytel’s clients, North Shore Physicians Group (NSPG), which is part of Partners HealthCare in Boston, has engaged the services of the Virginia Mason Institute to help apply the same Lean methodology (aka the Virginia Mason Production System) at NSPG’s primary care practices.

Applying Lean to Healthcare

This book is important for any organization that is wondering how Lean applies to healthcare (after all, the origins of Lean are in the Toyota Production System). Even if your organization is already in the process of implementing Lean or a similar total quality management (TQM) methodology, it is a very engaging read. It is written in narrative form — no “how–to” or value stream maps — and it really brings the Lean principles to life.

Incorporating Population Health Management

One chapter clearly stands out for me: ”Ambulatory Care Breakthrough” was compelling because I could connect what was in the book to what I observed when I visited NSPG’s flagship clinic in Danvers, MA to start collaborating with NSPG to incorporate our care management and population health solutions into their Lean workflows.

VMMC assembled a precursor to Phytel’s Outreach and population health solutions, starting with paper medical records, computerized billing systems and new roles for medical assistants and care managers as they work with patients who schedule appointments — but it has taken almost 10 years to develop.

Care Management Using Lean

We can use their example to help clients like NSPG implement care management in a manner consistent with Lean principles. However, by leveraging technology and adopting a total population perspective, our products go even beyond what VMMC describes they have done for primary care by engaging more patients more persistently to achieve true population health management.