Using industrial processes to improve patient care
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7432.162 (Published 15 January 2004) Cite this as: BMJ 2004;328:162
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"Six Sigma" afficionados are fond of using statements to the effect
that observations which are 6 standard deviations (ie, 6 sigmas) from the
mean occur roughly once in every 3.4 million (10^6) opportunities.
This is quite patently false. A casual inspection of the normal
distribution will reveal that observations exceeding 6 standard deviations
have a probability of roughly 1 per billion (10^9) opportunities, and that
the 1 per 3.4 million figure actually corresponds to about 4.5 sigma.
The discrepancy stems, I think, from Shewart, who said that there is
basically about 1.5 sigma of "slop", or "wiggle room" in the position of
the mean in most systems, so that if we target 6 sigma, anything between
4.5 sigma and 7.5 sigma is probably good enough.
This is admittedly a pedantic point, but it seems deliciously ironic
that advocates of such precision can't seem to get their own dogma right.
Competing interests:
None declared
Competing interests: No competing interests
As leaders within the NHS Modernisation Agency (MA) we were delighted
to see the paper by Terry Young and colleagues, which summarises 3 key
approaches to improving delivery systems in manufacturing and proposes
that they be applied to improving healthcare. (1)
Service improvement programmes in the MA have been applying key
elements of these approaches for several years (2). This new way of
improving services has gained credibility and the time is right to be more
explicit about the origins of the methods we use and how we have adapted
them successfully to the complex environment of NHS healthcare systems.
We now refer to this body of knowledge as ‘Clinical Systems
Improvement’. At its’ heart is the graphical presentation of key measures,
and their analysis using Statistical Process Control. Innovations are
planned and executed on a small scale, key measures are monitored to see
whether changes to the system have made a significant impact and determine
whether improvement has occurred before the change is rolled out. Data is
presented in a format that is easy to understand and statistically valid.
The approach seems to appeal particularly to doctors, who have been
calling for ‘evidence based management’.
In manufacturing, spread of this knowledge took many years, but the
NHS cannot wait that long. The big challenge for the NHS is how to harness
the capacity of those who have acquired the skills, experience and a
proven track record so as to spread them rapidly to all our staff. We have
had success in applying these methods to emergency flows (3), journey
times in cancer care (4), and elsewhere.
The Improvement Partnership for Hospitals (IPH) has been gathering
together capability, knowledge, skills and experience from all our
modernisation programmes (5,6). We are learning how to apply the methods
across entire organisations so as to improve care across several
dimensions - for example in Nottingham City total elective admissions have
been increased by more than 8% and cancelled admissions for surgery cut in
half by concentrating mainly on improving the emergency pathway and
reducing medical outliers. Chaos has reduced and there are clear benefits
for both staff and patients. There is growing realisation that emergency
admission rates are much more constant and predictable than intuition
would suggest and, for many hospitals, variability in discharges and
elective admissions are more important causes of overall mismatch between
capacity and demand for in-patient beds.
IPH is now distilling the collective knowledge within the MA into a
learning programme. This is designed to help the current generation of
senior managers and clinicians to reform their local healthcare delivery
systems. We will deliver the learning programme to most acute trusts in
England, tailored to local pressures and needs. We are integrating our
work with a parallel roll - out of improvement in primary care and a
similar programme is being set up for mental health services.
Publication of our methods and results in journals such as the BMJ
would help to spread awareness and encourage clinicians to be more
involved in improving their own services. It could lead to a fruitful
discussion of the application of manufacturing methods to healthcare
improvement. A long-term strategy will be to include quality improvement
in undergraduate and postgraduate education and, particularly, in training
for clinical and managerial leaders. Our vision is that staff in all
healthcare organisations will have the capacity to continuously improve
their own services, based on the priorities of their patients, and that
together we will drive up the quality of healthcare in the NHS.
1. Young T, Brailsford S, Connell C, Davies R, Harper P, Klein J.
Using industrial processes to improve healthcare. BMJ 2004;328:162-4.
2. Silvester K, Chaos the enemy of quality. Clinician in Management
1997;6:9-13
3. Walley P. Designing the accident and emergency system: lessons from
manufacturing. Emergency Medical Journal 2003;20:126-30
4. Kerr D, Bevan H, Gowland B, Penny J, Berwick D. Redesigning cancer care
BMJ 2002;324:164-6
5. White C. Improvement initiative rolled out for acute trusts in England
BMJ 2003;327:768
Competing interests:
None declared
Competing interests: No competing interests
It is rather surprising in an article about this subject to find no
reference at all to some of the excellent work by parts of the NHS
Modernisation Agency. These have been using a number of these techniques
with what seems to be some very impressive results. The most interesting
seem to be where clinicians have adopted and adapted the techniques rather
than simply applying the industrial model. Come to think of it these
really interesting and I think important results have been absent from the
pages of BMJ as well.
Competing interests:
None declared
Competing interests: No competing interests
The authors imply approval of 'maternity services' for already
dislaying some 'lean' characteristics, citing lack of waiting lists as
evidence. This is clearly a natural phenomenon resulting from a fairly
fixed gestational period, and has nothing to do with managment strategy or
intervention. The fact that babies won't wait can be used as a managment
tool to shoehorn patient demand into available resources, irrespective of
true safety considerations.
The other side of the coin is, however, that it is these same
maternity services which account for the lion's share of the Clinical
Negligence payouts from the NHS budget Perhaps a less 'lean' service
would allow this waste of money and lives to be reduced.
The authors, and the disciplines they represent, should distinguish
between 'fit and lean' and 'almost starved to death'. The latter
description is tha one that most who work in the NHS would deem the more
accurate.
Competing interests:
None declared
Competing interests: No competing interests
I was a member of a small party of South Australians who visited a
number of London Emergency Departments in November 2003. We were very
impressed by the way that those departments, which included both District
Hospitals and tertiary centres, had been transformed from 'war-zones' into
well functioning departments. This transformation seemed in no small part
due to the introduction of strategies such as improved flows into majors
and minors, strategies derived from Lean thinking, and championed by
groups from the Modernisation Agency.
Whilst I enjoyed this article, I think the authors underestimate the
extent to which concepts derived from industrial processes represent new
paradigms for health care, paradigms that have the potential to powerfully
influence the way health care is provided. The shift towards care
processes and patient flows is a major conceptual leap for practitioners
who are used to concerning themselves with the evidential content of
practice rather than with its flow. This shift is the major contribution
of the methods derived from industrial processes, and the authors
underplay its importance.
Though the authors seem enthusiastic about the potential for computer
simulations, I am less convinced. The underlying statistical assumptions
in most simulations are both complex and opaque to clinicians, and
simulations are hard to generate. Practitioners are rightly wary of
methods whose basis is hard to understand
Competing interests:
None declared
Competing interests: No competing interests
Improved Patient Safety through Cultural Change
The increasing awareness of the frequency and significance of medical
errors and the associated costs to the individual and community creates an
imperative to implement systems that improve the safety of healthcare
delivery. (1)
Errors occur… and errors can be prevented. Other high risk industries have
shown us that the collection of data on errors and incidents, and the
subsequent evaluation can contribute significantly to safety.
The national reporting and learning system (NRLS) as reported by
Katikireddi (2) is a step toward improving patient safety in the NHS.
However, a system for reporting, collecting and analyzing data will only
be successful if the workplace environment supports the reporting of
errors.
Lack of reporting of errors is the most important barrier to
improving patient safety. The vast majority of errors are not reported.
They are not reported because of the fear of reprisal.(3)
Traditional responses to errors in healthcare have been to blame the
individual. Fundamental changes in thinking are essential if progress
is to be made in reporting of errors. Causes of error must be seen as
faults of the system and not faults in individuals. (4) A focus on
individuals diverts attention away from the systemic issues, and therefore
away from the opportunity of systemic improvements.
The high risk industries in which reporting systems have succeeded,
did so through the consistent achievement of a ‘safety culture’. The
approach to errors was non-punitive and proactive, with a focus on sharing
and learning, awareness of the limitations of human performance and the
importance of effective teamwork.(4) Essential to the achievement is
commitment from top management, with continually improved patient safety a
declared and serious priority objective.
The importance of a strong culture of safety is viewed by many as
being the most critical underlying feature of their accomplishments in
improving safety. The NRLS can positively contribute to healthcare safety,
but only to the extent that management prioritize patient safety and
institute a rigorous cultural change in regard to reporting of errors.
Cultural change is essential if improvement in patient safety is to be
achieved.
1.Kohn CT, Corrigan JM, Donaldson MS. To err is human: building a
safer health system. Washington: National Academy Press, 1999: 1-6.
2.Katikireddi V. National reporting system for medical errors is launched.
BMJ 2004; 328 (7438): 481-a.
3. Kohn CT, Corrigan JM, Donaldson MS.Chapter 8:Creating safety systems in
healthcare organizations. To err is human: building a safer health system.
Washington: National Academy Press, 1999: 134-174
4.McNeil JJ, Ogden K, Briganti JE, Loff B, Majoor JW. Chapter 2:Literature
review. Improving patient safety in Victorian hospitals.
Victoria:Department of Human Services, 2000:5-21
Competing interests:
None declared
Competing interests: No competing interests