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The power of

Six Sigmas impact on the healthcare industry

Today, process improvement is being largely driven by Joint Commission JCAHO standard, LD.3.15, which basically implies that starting in 2006 every hospital would need a plan to improve patient throughput, requiring healthcare organizations to assess patient throughput to avoid bottlenecks that might compromise the quality of care. Most recently Joint Commission LD.01 Hospital Accreditation Leadership Chapter effective Jan. 1, 2009, focuses on elements of performance that include process improvements aimed at recruitment and retention of staff, space allocation, and processes for improved patient outcomes and incorporation of evidence-based information for improvement of services and processes. Aligned with Joint Commission standards and more familiar to the architectural world is the 2006 AIA Guidelines for Design and Construction of Health Care Facilities specifically Section 1.2.2.1.2 in reference to Environment of Care components to be addressed during functional programming. Briefly, these components address design through people, building systems, operational efficiency and physical environment. The pressure of the Joint Commission and AIA standards and guidelines is forcing healthcare environments to evaluate and improve operations in an effort to reduce medical errors, improve quality, profits, employee retention and patient satisfaction. There are many recent efforts to advance quality in the healthcare industry, one of them with the 2000 and 2001 publications from the Institute for Healthcare Improvement: To err is human: building a safer health system and Crossing the Quality Chasm: A new health system for the 21st Century. The center spurred an incredible effort to improve quality with two very successful campaigns advocating saving lives through prevention of medical errors: The 100K and the 5 million lives campaign. These campaigns challenge hospitals around the country to save lives through medical error prevention within a set period of time. The 2008 advisory committee national meeting series on The Clinical Mandate Balancing Investments in Quality and Efficiency to elevate Hospital Performance on the achievement of zero defects in healthcare services is another example of efforts on the eradication of medical errors and efficiency.

Process improvement integration in healthcare facility design

By Eileen D. Trimbach

treamlining processes is a priority for industries such as healthcare, especially when operating margins are low and strategic metrics, score carding and patient postoccupancy reports are rating hospitals on quality care while containing costs and keeping a healthy financial performance. This keeps the competitive edge very sharp. There are several approaches to improvement of patient care through process improvement that have materialized in the healthcare industry. Evidence-based design is well known in the design community, but most recently another entity is quietly commanding presence in the industry: Lean and Six Sigma for healthcare. Process improvement is an ancient tool. Lean and Six Sigma tools started in the manufacturing industry in the 1980s when Motorola adopted them to improve quality, and they shared the process with many companies in varied industries. It comes with acronym tools, hard data and interpretation of data for the best decisions for internal process improvements to eliminate errors and is based on a myriad of older management and quality assurance methods such as TQM and Zero Defects. Although formed from old tools, Lean and Six-Sigma are relatively new concepts in the healthcare industry.

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simulations and proof of hypothesis and/or incorrectly interpreted in facility planning, it can become very costly. Likewise, if performed properly, process imIn basic words Lean is a system that eliminates provement tools can help inform design decisions that process waste and Six Sigma makes use of statistiotherwise could be costly if erroneously translated into cal data to eliminate defects. This is being used to the physical world. streamline processes related to patient care in search Other potential challenges may become evident of profitable margins and lower operation expenses by when the project team is struggling reducing turnaround times and costs to evaluate process improvement in but still keeps high patient satisfaction tandem with coordinating leadership and quality of service. Six Sigma uses > on master planning or schematic what are called deployment teams Define Measure Analyze Improve design, and incorporation of owner with titles such as Executive LeaderControl basically focuses on driven efficiency solutions into the ship, Champions, Master Black Belts, existing process improvement facility design that possibly may be Black Belts, Green Belt and Yellow Belt brought to the designers attention that span across the organization for > during the later part of the design maximum project buy-in and mainDefine Measure Analyze Design process. tenance. It focuses on two main key Verify basically focuses on Some critics claim that Six methodologies, DMAIC and DMADV. creating new process or product Sigma stifles creativity, especially in There are several other acronyms research environments that it is and Six Sigma specific terms, and designed to fix existing problems, but with no vision for many focus on continual improvement and may be future growth or ideas for new opportunities. In CNN used for improving everyday routine tasks in a short Money Fortune, Vishva Dixit, vice president for research amount of time. of Genentech, a firm that accounts for 800-plus scienFor example, kaizen, the Japanese word for imtists researching cancer drugs, said, Innovation is a provement, was the basis for an emergency department meta-stable-entity, nothing will kill it faster than trying process improvement project at Memorial Hermann to manage it, predict it and put it on a timetable. Southwest Hospital in Houston. For this particular project one of the improvements of the kaizen was standardizing exam room layouts in addition to a few >>> in basic words lean is a system that other general operational solutions in relation to patient eliminates process waste, and six sigma makes transport and coordination of inpatient beds. These tools are used for improving everyday routine use of statistical data to eliminate defects. tasks in a short amount of time, but they also are being used internally by hospitals to evaluate the healthcare facility and operations specific to their facilities in an efIntegrating Six Sigma in established fort to improve efficiency in care delivery with long-term environments impact. In terms of evidence-based design activities, the It may be argued that most of these process improvedeployment teams may become part of the interdisciplinments may be operational in nature, and although not ary team that has been created to be part of an approach too evident at first, operational improvements have evsimilar to evidence-based design or in conjunction with erything to do with facility design. In the healthcare inthat design. dustry some environments where efficiency of process Custom simulation rapid modeling software focuses as it translates to facility utilization becomes crucial for on event simulation using chronological data and logic profit margins are operating rooms, clinical laboratories to simulate and improve existing processes. These and emergency departments. Process improvements in products are another example of process improvement these environments may, in some instances, translate tools presently being used in healthcare environments into improving the facility in layout or operation to in response to the human factor demands. They borrow achieve a certain efficiency goal. from longtime use in the military and other industries. Architects have traditionally used industry standard efficiency ratios to design major medical healthcare spaces that generally had no scientific backing readily There are always challenges available. Efficiency ratios may vary from facility to These process improvement tools can be very facility depending on the shape of the building, and inhelpful, although if the wrong data is used to formulate

What are Lean and Six Sigma?

DMAIC

DMADV

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dustry standard ratios have historically been used as a guideline for programming. A recent study published in 2008 on current ranges of efficiency ratios titled Analysis in Departmental Area in Contemporary Hospitals: Calculation Methodologies and Design Factors in Major Patient Care Departments by David Allison, AIA, ACHA, Clemson University and D. Kirk Hamilton, AIA, FACHA, Texas A & M University, illustrates the wide range of ratios varying from facility to facility. The introduction of process improvement tools may bring with it statistical data specific to a facility that has the opportunity to inform on efficiency ratios specific to a facility, thereby possibly informing the interior space design programming more accurately. Many of these efficiency ratios may not be transferable from one facility to another and may be specific to a culture/environment because of variability of data and varied constraints that may exist in one environment but not in another. The introduction of a variety of process improvement efforts may shift project design process from what is presently known and take more of a non-linear project approach. Although architects are already accustomed to collaborative work during the design process, this owner driven element brings about an additional point of collaboration. With the onset of evidence-based design, collaboration among designers, researchers and Lean and Six Sigma deployment teams would start early in the design process during the formation of what would term an interdisciplinary team at the visioning/programming stage of the design process. The Six Sigma deployment teams may become part of the interdisciplinary team that has been created to be part of an evidence-based design approach aiding the project by helping inform design solutions of specific spaces where the process improvement affects the physical layout of the facility. Lean and Six Sigma methodology also is used in ways other than for space planning. According to Tom Kinman, PE, vice president of facilities management at Cincinnati Childrens Hospital Medical Center, his organization uses an intermediate Six Sigma methodology to inform standard deviation on space utilization at various points for Joint Commission purposes. This data helps the facilities department track patient room turnover at discharge to allow them to identify optimal blocks of time to do any infrastructure maintenance needed in addi-

tion to conduct any material management supplies into the spaces. However, according to Kinman, efficiency evaluations prior to proceeding with any construction project would be beneficial since many departments get over-programmed due to the vague flux of spaces. This over-programming greatly affects facility MEP infrastructure, by identifying spaces that have many parallels in processes early on, it could possibly help minimize the design of non-value added spaces by identifying opportunities for flexible departmental expansion without investing in bricks and mortar, such as providing space adjacencies to allow for overflow from one department to another on specific shifts, Kinman said. Ideally, the process improvement investigations that would impact the facility design would be introduced into the project very early during programming. Efficiencydriven projects would benefit from identifying the areas of desired improvement at the inception of the project and begin data gathering and formulating hypothesis very early in the design process, as early as the visioning stages, regardless if it is part of an evidencebased design process or a stand-alone process improvement application. Introduction of efficiency-driven facility changes to a project during design development and construction documents becomes more challenging to incorporate into the documents due to the implications of design change ramifications with all consultants involved. Similar efficiencydriven design revisions become prohibitive during construction. It must be made clear that activities such as data collection and hypothesis implementation must be intertwined into the design process as early as the pre-design phase of the project in order to be effective and least disruptive to the design process at later phases. A benefit to the healthcare community is that the process improvement knowledge base of Lean and Six Sigma is specific to the project at hand, is created with in-house knowledge collaboration, stays in-house and is constantly maintained in-house. n
Eileen D. Trimbach, AIA, LEED-AP, EDAC, is a healthcare architect with DNK Architects, Inc., in Cincinnati. She also is an evidence-based design accreditation collaborator with the Center for Health Design.

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