Standardize your processes! You can save time, money and prevent errors. Things
you do over and over should be done the same way every time, if indeed you do the
task the best way. They say variety is the spice of life, but for healthcare processes
it certainly isn’t most of the time. Consider this, if you would. Would you buy your
favorite brand of soda if sometimes your 12 ounce can were 3/4 of the way full and
sometimes almost overflowing. Certainly not. You expect there to consistently be
nearly 12 ounces every time. How would a patient behave if the results of a
healthcare visit varied wildly? The patient would probably find a new provider. The
best healthcare providers deliver a consistently good service; it helps attract new
patients and keeps the old ones coming back.

Standardization helps save time. As things become routine, a process is easier to
do and is done more quickly. For instance, if a primary care physician makes sure
that the necessary items for a patient visit are always in the examining room, the
doctor won’t have to waste time going to look for supplies and waste time for the
patient or the doctor. I recommend that primary care physicians along with staff sit
down and list the things that should always be in examination rooms and make sure
someone is responsible for these items every morning before patients arrive. If this
is done, the doctor can save time, thereby enabling him or her to spend more
quality time with the patient or see more patients.

Standardization saves money. Most doctors face rising malpractice costs, but for
one group this has not been trueanesthesiologists. According to an article in the
June 21, 2005 edition of the Wall Street Journal, this group over two decades ago
began implementing procedures that ensured the safety of their patients. Certain
processes have been standardized across the profession so instead of one death per
5000 cases, there is now only one per 200000 to 300000 cases. Because of this,
their malpractice insurance premiums plummeted.

Standardization prevents errors, as in the above illustration. Another example is
drawn form a local hospital. Recently the Chief Financial Officer of the institution
and I were discussing the new facility they were building. Instead of building
adjacent rooms so that the bathrooms would be back to back to save plumbing
costs, each room was designed so that each room will be exactly the same with
bathrooms all on the same side. Why? This will prevent errors and in the long run
save money for the hospital.

It is best if you can measure standardization. The best tool to measure
standardization in statistics is variance or standard deviation. I am sure many of
you have encountered this measure, but probably cannot calculate it. The best way
to calculate it is either in a spreadsheet or on a calculator. For example, the
standard deviation for the numbers 8, 12, 1, 4 and 5 is 4.18. For the group 5, 5, 5,
5, and 5 the standard deviation is 0, since there is no variety. So, when you are
trying to standardize a process, see if you cannot find some significant measure
that reflects the process and try to reduce the standard deviation as much as
possible. In fact, this is the heart of Six Sigmareduce the standard deviation as
much as possible. The best manufacturers and service providers often use this tool.

Once you have standardized a process and have achieved a satisfactory standard
deviation, then write down the process in a manual that is a collection of all best
practices. This way, anyone who needs to reference how a process should be
conducted can refer to the manual. Too, it is an excellent training source for new
employees.

As you can see in these brief illustrations, standardization or the lack of variance
provides safety for patients, a savings of time for the provider and patient, and
contributes to an improved bottom line.

Mr. Bryant helps healthcare providers meet their challenges. He helps save
time, improve patient health, and improve the bottom line. He publishes a
monthly newsletter “Making Good Healthcare Better.” All of this is done from
the perspective of a certified quality engineer and statistician.

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The best quality improvement initiatives are driven by data! Why? How are you
going to know how much you have improved if you don’t measure something?

All of you have been exposed to measures in many situations. Most of them were
important. In school, you were graded. Perhaps you own shares of stock; how do
you measure the success of the stockits increase in value, a measurement. How
do you know if your team wins? By its score, a measurement. The fact is that many
daily activities in life have accompanying measures to judge their success.

You might argue that you know if things are getting better; you can just tell. I am
sure that you can. This is not enough, though. In the healthcare field it is
important to measure improvement. One reason to do so is to prove to others that
things are improving. For instance, suppose you are in charge of implementing
electronic health records in a hospital setting. You meet resistance from several
staff members, including a large number of doctors. How can you overcome this
resistance? Collect datalower percentage of wrong prescriptions, for instance
from a pilot program of willing participants and then demonstrate the positive
benefits with your data. With such results in hand, you will overcome many
doubters.

Another reason to measure improvement is to demonstrate the saving of time and
money. With healthcare costing so much today that many find care out of their
price range, it is important to find ways to lower costs. For instance, suppose that
staffing at your facility is very expensive; the payroll costs are way over budget. I
recently read of a lean six sigma project that demonstrated through the use of data
collecting by staff charge nurses that staffing shortages and costs were significantly
reduced. The right staff was present when needed and the facility eliminated the
need for using short-term staffing of nurses through agencies; this saved a great
deal of money. Besides lowering costs, staff morale improved significantly at this
site.

I hope that I have convinced you that to make significant quality improvements, you
should be actively measuring. What should you be measuring? The most common
measurements are costs in providing a service, time taken in providing a service and
various measures of patient health, such as the lung capacity of asthmatics. You
can also measure improved bottom lines. One doctor I know improved his income
38% in 5 years by working hard to adopt quality measures in his solo practice. Many
ER’s now boast of how they have significantly decreased waiting time for patients.
One such local hospital did so well that they were overwhelmed by the increase of
demand for service at their ER. You might want to measure if spending a few more
minutes with patients talking about pursuing good life habits like eating the right
foods leads to improved health, like lower cholesterol.

Once you have decided what to measure, you should first measure the variable
(cost, time, etc.) as it is in the state before you begin an improvement initiative.
This is a baseline against which you can measure your improvement. As you begin
and proceed through a quality improvement effort, keep track of the measures and
see what improvements occur. I suggest that you keep the data in a spreadsheet or
database. For short term record keeping you might want to use charts. You will
want to check to see if your means are significantly improving (you can use
statistical tests if you choosethey are more accurate) and if your variation is
decreasing.

Once you have reached your goals, revisit the new processes once in a while and
collect new data on the variables you chose to measure. Doing so, will help keep
you from backsliding to the old ineffective state. Backsliding is all too easy. It is
hard to break old habits, but keeping data will help you. This is, in fact, what drives
the the success of many programs, such as Weight Watchers.

I hope that I have convinced you that data driven change is the best way to approach
quality improvement. It will concretely demonstrate how you are progressing and
will prove to others that your site is doing much better. It will help you earn your
just rewards!

Donald Bryant helps healthcare providers meet their challenges and writes
“Making Good Healthcare Better” a free monthly ezine for healthcare
providers who want to dramatically improve patient health, improve the
bottom line, and make work more rewarding, guaranteed. Go now to his
http://www.bryantsstatisticalconsulting.com to get a free article with tips you can
use to start making improvements immediately and to learn more about Lean Healthcare

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I want to tell you some ways to eliminate waste at your medical site. Am I talking
about physical waste, like soiled bandages or used needles? No, I mean any action
that results in a poor or unintended outcome. I mean taking too long to accomplish
some outcome, like taking too long to get an operating room ready for the next
surgery. The National Institute of Health in “Crossing the Quality Chasm” stated
that any waiting time for a patient is a waste. A patient waiting past the time of his/
her scheduled appointment is an example. A patient having to wait too long to be
admitted to a hospital after being seen in the emergency room is an example of
poor processesa waste. A patient who develops an infection after being treated or
going through surgery is a good example of waste from unintended outcomes.
These are just a few examples. I am sure that you are aware of many more.

Japanese manufacturers are leaders in eliminating waste. One trick they use is to
send a new employee to the manufacturing floor and have him/her watch someone
performing a task; the new employee is told to watch until he/she sees a better way
to do the job. These manufacturers know that the time spent doing this will save
more time and money in due time. Hospitals and healthcare sites are not
manufacturing plants, though. Yet many of the same principals can be applied. The
effort will more than pay for itself. In fact, savings of 3 to 100 times the investment
is not unusual. The movement going on in the healthcare field adapted from the
Japanese manufacturers is commonly called “lean healthcare.” Perhaps you have
heard of some of the terms associated with it, like Kaisen events or poka-yoke. You
don’t have to be a master of these tools and terms to make good use of them,
though. Many are just applying logic with common sense.

The tools are best applied in efficient working teams or groups where some
problems with processes or outcomes are already agreed upon. If the working
group is larger than 3 or 4 people I suggest that one tool you use are string and 3
by 5 cards. You are going to use these to map out a process from beginning to end
and see if the group can find waste and suggest ways to eliminate it. Use the cards
to describe what physically happens during a process and use the string to connect
the activities that flow from one to another. For example, you might want to track a
patient in a doctor’s office coming in for a physical. The first card would represent
the patient’s encounter with the first staff person who records the patient’s
presence. From there, strings would indicate communicating with other pertinent
personnel of the patient’s presence and the ensuing events as well a string and card
that would indicate the patient waiting in the waiting room. In all of these mappings
you should be thinking of what you would like to use as variables to measure. You
certainly should be measuring time by all involved parties. You might also want to
count the number of successes/failures in communications. Many unintended
consequences occur at transition points and handoff points due to poor
communication. You might count if a supply was missing and someone had to
scurry to find another one. You will want to later find the mean and standard
deviations of these measures. The goal is achieve a target mean with as small as
possible standard deviation. For example, you should have 0 as a target for the
number of times a supply was missing.

After reaching a mapping that all agree represents as best as possible the present
flow of events, the group should brain storm ways to improve the flow. The goal is
to find a significantly better path. If a consensus is reached, fine; implement it. If
not, then perhaps you will want to try the various ways and then decide which is
best, based upon agreed upon measures of outcomes.

Once an optimized process is developed by the staff, you should write it down.
Make it a standard operating procedure and try to have all involved parties adopt it.
You might want to allow a little bit of wiggle room for individual differences in
performing a task; the goal of a common target with small standard deviation
should the goal of all, though.

Another tool to use is open communication. Too often a staff person or nurse will
see some event unfolding that will lead to poor outcomes. If the work environment
is not conducive to positive communicationcommunication which does not result
in negative outcomes for the reporting individualmistakes and waste will always
occur that could easily have been prevented. To reach a high level of positive
communication, the leaders at a site must work long and patiently to build trust. It
is not easy to do, but the payoffs are tremendous. Everyone wins!

Most healthcare leaders think of quality improvement as applying to activities that
directly involve the patient. However, the best healthcare providers use these tools
and others to evaluate all the processes at a healthcare site. The admissions and
billings departments are ripe targets, for instance. The result will be happier, more
motivated employees who are working more efficiently. In fact, sites which were
experiencing a shortage of staff often finding themselves well staffed because of
quality improvement processes. I do suggest that you promise all employees
involved in these processes that you guarantee there will be no layoffs. Doing so
will produce better outcomes.

If you want more examples of system wide applications of quality improvement in
healthcare facilities, I suggest that you go to the Baldrige Award site on the internet
and read the success stories of winners. Their results will amaze you, I promise.

I hope that you seriously consider adopting these tools and research other methods.
Many are described at various healthcare sites. Two of my favorites are Institute for
Healthcare Improvement and the American Academy of Family Physicians.

Donald Bryant helps healthcare providers meet their challenges and writes
“Making Good Healthcare Better” a free monthly ezine for healthcare
providers who want to dramatically improve patient health, improve the
bottom line, and make work more rewarding, guaranteed. Go now to
http://www.bryantsstatisticalconsulting.com to get a free article with tips you can
use to start making improvements immediately and to learn more about Lean Healthcare

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