LEAN - SIX-SIGMA FOR HEALTH CARE

                     Lean is a philosophy and set of management techniques focused on continuous “eliminating waste” so that every process task or work action is made “value adding” as viewed from customer perspective. Lean “waste elimination” targets that “seven wastes” namely

Seven Wastes of Healthcare:
  •   Overproduction
  • Transportation
  •   Motion
  •   Waiting
  •   Processing
  •   Inventory
  •   Defects

Lean is a systematic way of designing or improving a process or value stream that is,
  • Eliminates waste
  •  Improves quality
  •  Reduces costs
  •  Delights customers
  • Improves employee satisfaction
  •  Increases safety

Lean six-sigma is actually doing more with less,
  •  Less time
  •  Less space
  •  Less human effort
  •  Less equipment
  •  Less material
Lean is the relentless reduction of waste or non-value added activities
  Waste is defined through the eyes of the customer

  Anything that does not add value to the final product or service
  Activities that the customer would not want to pay for if they knew they were     happening
·         Examples of non-value added activities
o   Approving
o   Batching
o   Searching
o   Walking
o   Waiting

  A Pareto is a specialized bar chart that breaks down a group by categories and compares them from largest to smallest. It is used to look for the biggest pieces of a problem or contributes to a cause, the Pareto chart helps you figure out which of the few issues or problems have the most impact, so you can focus your projects and solutions on those few,  most impactful issues. The Pareto chart capitalizes on the so-called
“80-20 RULE”: most of the problems (80) arise from relatively few causes (20).
The purpose of pareto analysis technique is to provide a means for identifying the key factors that have the highest occurrences in any given situation, to enable prioritization and focus of problem solving efforts, to aid in the analysis of the current situation with respect to activity performance, service, or quality and to monitor the effectiveness of solutions once implemented.

   A popular technique is the cause-and-effect, or fishbone or Ishikawa, diagram. In addition to having a lot of names, this tool borrows from other tools. The fish bone is used t o brainstorm possible causes of a problem and it puts the possible causes into group, or affinities; causes that lead to other causes are linked as in a structure tree. The value of a cause-and-effect diagram is to help gather the collective ideas of a team on where a problem might arise and to help the team members think of possible causes by clarifying major categories.
  Cause-and-effect diagrams do not tell you the right cause. Rather, they help you develop educated guesses, or hypotheses, about where to focus measurement and further root cause analysis
·         FLOW CHARTING:

                       These are termed as the “PROCESS MAPPING.” A flow chart is used to show the details of a process, including tasks & procedures, alternative path, decisions point, & rework loops. A flowchart   can be depicted as an “as-is” map showing a process as it currently works or as a “should-be” map showing how it ought to work. The level of details will vary, depending on the objective. Many black belt now use software to draw their flowcharts but often start with a bunch of stickies on a wall. Processes are the most effective way to manage an organization at any level and eventually support its overall goals. By improving processes, a business or organization can improve internal efficiencies, effectiveness, adaptability and customer service levels.

Documenting processes involving people, particularly employees, can lead to insights and changes that can help improve an area or operation. One way to understand a process is to start thinking about its major elements - inputs, outputs, activity steps, decision points, enablers and functions.
Improving processes include:
  • Eliminating entire processes or sub-processes that are unnecessary.
  • Automating manual activity steps.
  • Combining steps.
  • Outsourcing elements of the process.
  • Changing the location where steps are done or the people performing them.
  • Altering or modifying how activity steps are done.

            Many six sigma methods have brainstorming, or idea generation, as a starting point. The basic purpose of brainstorming is to come up with a list of options for a task or a solution – usually a longer list that is shortened into a final choice. For example, a team may brainstorm which customers to interview or what questions to ask. Later, the team may use brainstorming again to list possible measure and still later to come up with creative improvement solutions. A problem with brainstorming is that everybody thinks they are good at it. In fact, it takes work and discipline to be truly creative.


1. Six Sigma: Using Statistics to Reduce Process Variability and Costs in Radiology

AUTHOR: Jean Cherry, M.S. FACHE and Sridhar Seshadri,

In many corners of the corporate world, Six Sigma has developed a reputation as the mother of all quality initiatives. Pioneered at Motorola Corporation in the 1980s, Six Sigma is a quality initiative based on rigorous statistical process control. It augments traditional quality tools with exacting statistical analysis and a systematic problem- solving approach, targeting the root cause of variations and redefining processes for long-term results. The methodology has been used in a variety of settings to solve a broad array of issues: from improving manufacturing capabilities to customer service to aircraft design…and everything in between. It has been used to transform organizations of all types and is now beginning to be applied in healthcare. . “Sigma” is the Greek letter used by statisticians to define standard deviation from the norm. A higher sigma indicates a lower rate of defects and more efficient processes. At Six Sigma, defects are roughly 3.4 per million opportunities, or nearly error-free. Consider this: Three Sigma translates into about 5,000 incorrect surgical procedures each week nationwide, a somewhat less than desirable ratio.

2. Lean Sigma— Will It Work for Healthcare?

AUTHOR: James A. Bahensky, MS, Janet Roe, and Romy Bolton


The manufacturing industry has been using Lean Sigma for years in pursuit of continuous improvement to obtain a competitive advantage.The objectives of these efforts are to use the Lean techniques for reducing cycle times and the Six Sigma concepts for reducing product defects.The Iowa Business Council with several advocates worked with the University of  Iowa Hospital and Clinics (UIHC) and two other Iowa hospitals to determine whether Lean
Sigma is adaptable in healthcare.A team of 15 people at UIHC used the Kaizen Breakthrough Methodology over a five-day period in an aggressive identification and elimination of non-value added activities in Radiology CT scanning.The results exceeded the initial project objectives and indicated that Lean Sigma is applicable in healthcare. Overall, the Lean Sigma project increased revenue by approximately $750,000 per year.The Kaizen process proved to be successful and interesting.Within three days, the team installed new workflow processes.This implementation-oriented approach is what differentiates Lean Sigma from other quality improvement processes

3. Email Notification Combined with Off Site Signing Substantially Reduces Resident Approval to Faculty Verification Time.

AUTHOR:  Deitte LA, Moser PP, Geller BS, Sistrom CL.


Attending radiologist signature time (AST) is a variable and modifiable component of overall report turnaround time. Delays in finalized reports have potential to undermine radiologists' value as consultants and adversely affect patient care. This study was performed to evaluate the impact of notebook computer distribution and daily automated e-mail notification on reducing AST.Two simultaneous interventions were initiated in the authors' radiology department in February 2010. These included the distribution of a notebook computer with preloaded software for each attending radiologist to sign radiology reports and daily automated e-mail notifications for unsigned reports. The digital dictation system archive and the radiology information system were queried for all radiology reports produced from January 2009 through August 2010. The time between resident approval and attending radiologist signature before and after the intervention was analyzed. Potential unintended "side effects" of the intervention were also studied.

4.  New aspects of image distribution and workflow in radiology.
AUTHOR: Mack S, Holstein J, Kleber K, Grönemeyer DH.



The progressive use of digital image-generating devices and digital communication technology in clinical and practice environments implies changes in radiological workflow and asks for adequate quality assurance in the whole process of radiology report preparation. This improvement potential has to be rigorously reinvestigated with regard to up-to-date procedures and the full exploitation of supporting technologies like linguistic analysis, help desk and trouble ticket systems, competitive allocation algorithms, time-and-event monitoring, and intelligent agents. These approaches are to be evaluated in combination with business process analysis and shall help to reduce turnaround times for radiology reports while maintaining or even increasing quality-assurance levels.

5. Want to reduce report turnaround time? Try pay-for-performance

AUTHOR:   Kate Madden Yee

Cutting radiology report turnaround time is a key quality goal for hospitals. But administrators often find that simply emphasizing the importance of quick report turnaround through verbal or written communication doesn't necessarily produce better results.Dr. Giles Boland, vice chair of radiology at Massachusetts General Hospital (MGH) in Boston, oversaw a pay-for-performance program in the department of radiology to help reduce report turnaround time. Boland presented the program's results at the 2008 RSNA meeting in Chicago.
MGH measured mean report turnaround time for its 98 radiologists, including 10 subspecialty divisions, for three months before the program began and for 15 months after it had been initiated. The hospital offered a bonus of $5,000 annually for full-time employees and $2,500 for half-time radiologists.
Time from exam completion to preliminary report availability, as well as time from preliminary report to final signature, were measured in hours directly from the hospital's RIS. The radiologists used voice recognition software to perform dictation.
The pay-for-performance initiative at MGH withholds a financial bonus for those who do not meet the institution's report turnaround guidelines. The report turnaround goal varied according to the type of practice (for example, two hours for ER versus 24 hours for neurointerventional radiology).

6. Significant savings in radiologic report turnaround time after implementation of a complete picture archiving and communication system (PACS)

AUTHOR : Akram A. Twair, William C. Torreggiani, Salaheddin M. Mahmud, N. Ramesh and Brendan Hogan
One of the important advantages of the picture archiving and communication system (PACS) is the time saved in comparison with the conventional system. A group of 100 radiologic studies done in a conventional radiology department is compared with another group of the same number done in a completely filmless PACS department to assess the difference in the radiologist report turnaround time. There was a statistically significant (P<.00001) decrease in the median imaging-to-dictation time (IDT) of the PACS group (3 hours and 40 minutes) in comparison with the pre-PACS group (25 hours and 19 minutes). This can be attributed to the fact that PACS eliminates all the workload associated with hard copy films, thus, improving the department’s efficiency and decreasing the number of lost films.

7. Speech Recognition Reduces Turnaround Time of Radiology Reporting by 85%

AUTHOR : Medimaging International staff writers  Posted on 26 Aug 2010

A new speech recognition system offers front-end dictation possibilities for radiologists to easily produce and distribute authorized reports after-hours and during weekends.
Nuance Communications, Inc. (Burlington, MA, USA), a supplier of speech solutions, reported that its speech recognition technology has been utilized by the Nuance partner SolitonIT to reduce the time needed to create radiology reports, at the department of medical imaging, Nambour General Hospital (QLD, Australia), by 85%.
The average report-turnaround time, before the implementation of speech recognition at Nambour Hospital, was at 33 hours, now it is decreased to five hours. Together with the speech recognition technology, SolitonIT has delivered a fully integrated environment that links together key elements within the imaging department, the radiology information system (RIS) and the picture archiving and communication system (PACS). Workflow is far more efficient and risk of error has been minimized. “Previously the transcriptionists were constantly fighting with a backlog of audio files waiting to be typed. They never had a sense of achievement. They left on Friday evening, knowing that on Monday morning the report backlog would have further increased. It was demoralizing,” remarked David Ward. “Thanks to an integrated workflow and speech recognition our transcriptionists are much happier people.”
Centrally installed and managed at Nambour General Hospital, the system was quickly expanded to give Radiologists at Caloundra and Gympie Hospitals access to speech recognition. SolitonIT’s workflow solution utilizes the award winning Nuance speech recognition, SpeechMagic. An HL7 [Health Level 7] interface to the RIS and full desktop integration to the hospital’s PACS means that it is now virtually impossible for transcriptionists to type the wrong report for the wrong patient, explained David Ward.

8. The Radiology Digital Dashboard: Effects on Report Turnaround Time

AUTHOR : Matthew B. Morgan, Barton F. Branstetter, David M. Lionetti, Jeremy S. Richardson and Paul J. Chang
As radiology departments transition to near-complete digital information management, work flows and their supporting informatics infrastructure are becoming increasingly complex. Digital dashboards can integrate separate computerized information systems and summarize key work flow metrics in real time to facilitate informed decision making. A PACS-integrated digital dashboard function designed to alert radiologists to their unsigned report queue status, coupled with an actionable link to the report signing application, resulted in a 24% reduction in the time between transcription and report finalization. The dashboard was well received by radiologists who reported high usage for signing reports. Further research is needed to identify and evaluate other potentially useful work flow metrics for inclusion in a radiology clinical dashboard.

9. Radiologist Report Turnaround Time: Impact of Pay-for-Performance Measures

AUTHOR : Giles W. L. Boland, Elkan F. Halpern and G. Scott Gazelle
Expedited finalized radiologist report turnaround times (RTAT) are considered an important quality care metric in medicine. This study was performed to evaluate the impact of a radiologist pay-for-performance (PFP) program on reducing RTAT.
A radiologist PFP program was used to assess its impact on RTAT for all departmental reports from 11 subspecialty divisions. Study periods were 3 months before (baseline period) and immediately after (immediate period) the introduction of the program and 2 years later after the program had terminated (post period). Three RTAT components were evaluated for individual radiologists and for each radiology division: examination completion (C) to final signature (F), C to preliminary signature (P), and P to F.

10. Ways to reduce patient turnaround time and improve service quality in emergency departments
AUTHOR: David Sinreich, (Davidison Faculty of Industrial Engineering and Management, Technion – Israel Institute of Technology, Haifa, Israel), Yariv Marmor, (Davidison Faculty of Industrial Engineering and Management, Technion – Israel Institute of Technology, Haifa,)
Recent years have witnessed a fundamental change in the function of emergency departments (EDs). The emphasis of the ED shifts from triage to saving the lives of shock-trauma rooms equipped with state-of-the-art equipment. At the same time walk-in clinics are being set up to treat ambulatory type patients. Simultaneously ED overcrowding has become a common sight in many large urban hospitals. This paper recognises that in order to provide quality treatment to all these patient types, ED process operations have to be flexible and efficient. The paper aims to examine one major benchmark for measuring service quality – patient turnaround time, claiming that in order to provide the quality treatment to which EDs aspire, this time needs to be reduced.
11. Radiology 2012: Radiology and Radiologists a Decade Hence—A Strategic Analysis for Radiology from the Second Annual American College of Radiology FORUM1
AUTHOR: Bruce J. Hillman, MD and  Harvey L. Neiman, MD
The American College of Radiology (ACR) FORUM brings together a multidisciplinary group of experts in a subject area that the ACR believes to be of long-term importance to the specialty of radiology. The goals of the FORUM are to develop scenarios about the way the future might develop with respect to the chosen topic and to advise both the ACR and the specialty on steps that should be taken to maximize the value and influence of radiology in the future. In May 2002, the FORUM brought together radiologists, health services researchers, specialists in medical technologies, representatives of the imaging industry, and payers to discuss the key drivers of the way medical imaging will develop over the next 10 years.

12. The Management of Radiologic Practice in Hospitals
AUTHOR: D. S. Beilin, M.D., Radiologist
The management of radiologic practice in hospitals is a very timely subject. This paper is not intended for those who are seasoned in hospital radiologic practice—I am sure there are many of you who are more competent to present this subject than I. However, I have been interested in this subject for some time, and the present paper is the result of observations and investigations, which have been made during the past five years. The ideas and facts presented have been effectively carried out in general hospital radiologic practice, during the same length of time. It is understood that no fast rules and regulations can be made, as many institutions have their individual problems. The size of the hospital, and the character of the practice, whether private or charity, as well as numerous other obvious factors, bear a definite relationship to the management of radiologic practice. In a relative, practical way the following aspects are of importance.
13. Radiology Management: The Advantages of the Dedicated Mini-computer
AUTHOR: Ronald L. Arenson, M.D.
When planning to automate management functions, a department must choose between using a dedicated mini-computer and the hospital's large central computer facility. Rapid response times and ease of program modification are important advantages of the dedicated mini-computer; moreover, limitations on transmission speeds and the variety of terminals available are disadvantages of the central computer facility. The substantial reduction in the cost of computers coupled with the availability of well designed data-base management systems which allow communication with other systems are additional reasons for selecting the mini-computer. In selecting systems that are already programmed, the department minimizes risks and implementation difficulties.
14. Comprehensive Analysis of a Radiology Operations Management Computer System
AUTHOR : Ronald L. Arenson, M.D. and Jack W. London, Ph.D.
The Radiology Operations Management computer system at the Hospital of the University of Pennsylvania is discussed. The scheduling and file room modules are based on the system at Massachusetts General Hospital. Patient delays are indicated by the patient tracking module. A reporting module allows CRT/keyboard entry by transcriptionists, entry of standard reports by radiologists using bar code labels, and entry by radiologists using a specially designed diagnostic reporting terminal. Time-flow analyses demonstrate a significant improvement in scheduling, patient waiting, retrieval of radiographs, and report delivery. Recovery of previously lost billing contributes to the proved cost effectiveness of this system.

15. Radiologist report turnaround time: impact of pay-for-performance measures.

AUTHOR: Boland GW, Halpern EF, Gazelle GS.


Expedited finalized radiologist report turnaround times (RTAT) are considered an important quality care metric in medicine. This study was performed to evaluate the impact of a radiologist pay-for-performance (PFP) program on reducing RTAT.
 A radiologist PFP program was used to assess its impact on RTAT for all departmental reports from 11 subspecialty divisions. Study periods were 3 months before (baseline period) and immediately after (immediate period) the introduction of the program and 2 years later after the program had terminated (post period). Three RTAT components were evaluated for individual radiologists and for each radiology division: examination completion (C) to final signature (F), C to preliminary signature (P), and P to F.

16. Strengthening your ties to referring physicians through RIS/PACS integration.

AUTHOR: Worthy S, Rounds KC, Soloway CB.


Many imaging centers are turning to technology solutions to increase refering physician satisfaction, implementing such enhancements as automated report distribution, picture archiving and communications system (PACS), radiology information systems (RIS), and web-based results access. However, without seamless integration, these technology investments don't address the challenge at its core: convenient and reliable, two-way communication and interaction with referring physicians. In an integrated RIS/PACS solution, patient tracking in the RIS and PACS study status are logged and available to users. The time of the patient's registration at the imaging center, the exam start and completion time, the patient's departure time from the imaging center, and results status are all tracked and logged. An integrated RIS/PACS solution provides additional support to the radiologist, a critical factor that can improve the turnaround time of results to referring physicians. The RIS/PACS enhances the interpretation by providing the patient's history, which gives the radiologist additional insight and decreases the likelihood of missing a diagnostic element. In a tightly integrated RIS/PACS solution, results information is more complete. Physicians can view reports with associated images selected by the radiologist. They will also have full order information and complete imaging history including prior reports and images. Referring physicians can access and view images and exam notes at the same time that the radiologist is interpreting the exam. Without the benefit of an integrated RIS/PACS system, the referring physician would have to wait for the signed transcription to be released.
17. The Path of Least Resistance: Is There a Better Route?
AUTHOR : Ann Loree, B.S., Marcia Maihack and Marge Powell, B.S., R.T.
Driven by nationwide technologist shortages, an industry-wide focus on quality, and rising consumer demand, healthcare is feeling the pressure to deliver more with less. Given this challenging environment, some organizations have come to the conclusion that taking the path of least resistance may not be the best approach. For most, delivering quality patient care is nonnegotiable and the ability to function at the highest level of efficiency while doing so is seen as a necessity… not a choice. Realizing and responding to this quandary a few years ago, California’s Stanford University Medical Center decided to aggressively work toward a solution and overcome resistance by approaching it with evidence.

18.Six Sigma strategy applied to the pharmaceutical industry.How customers

AUTHOR: Maria Jernelid and Steven Roan
The pharmaceutical industry is extremely large, dynamic and a highly profitable industry.
Pattison and Warren ( 2003, p 1 ) suggest that in 2002 the pharmaceutical industry pulled
in profits that far exceed other industries and accounted for profits “ five-and-a-half
times greater than the median for all industries represented in the Fortune 500”. Drug
discovery and development is however very expensive and the industry is plagued with
drug failures during the development stage. Including the costs of failures, developing
and taking a new drug to market, the estimated cost for drug development is in the region
of US$1.5 Billion and continues to grow year on year (Gassmann et al. 2008).The
industry is now faced with finding ways to improve productivity while meeting product
and customer, regulatory and efficiency demands.
A couple of issues differentiate the pharmaceutical industry from most other industries.
Firstly, consumers of pharmaceutical products often have very little say in the products
that they use. Secondly, the pharmaceutical industry is one of only a couple of industries
in which the patent protection essentially equals the product.
Six Sigma can be defined as many things, and to different people it may have different
meanings. Some will define Six Sigma as a methodology that aims to produce near
perfect production process. In numerical term, the vast amount of literature on the
subject is supported by Pande et al. (2000) who suggests that Six Sigma aims for a
performance target of only 3.4 defects for every million activities.

19. Implementing Lean/Six Sigma Methodologies in the Radiology
Department of a Hospital Healthcare System

AUTHOR: Jamie Workman-Germann, Heather (Woodward) Hagg.
Increased focus is being placed on the quality of care provided by Hospital Healthcare Systems around the country. Caught in the middle between tightening government standards, stricter compliance guidelines for insurance companies, and the basic mission to serve those in need with quality and compassion; hospitals are looking for ways to improve their processes (services) for the benefit of all. CT (Computed Tomography – CAT Scan) and MRI (Magnetic Resonance Imaging) services in the hospital radiology departments are revenue-generating areas. The reimbursement rates for these services are very high, the scan times (especially in CT) are relatively low, and so the potential for additional revenue to the hospital comes with increasing patient capacity for these services. However, it is also a very competitive time for hospital radiology departments as many outpatient diagnostic centers are being built, drawing patients and physicians to their fast, efficient, no hassles approach to imaging. This brings additional hurdles to the already struggling hospitals. The Sisters of St. Francis Health Services (SSFHS) group enlisted the aid of faculty at IUPUI.

20. Improving Report Turnaround Time: An Integrated Method Using Data from a Radiology Information System
AUTHOR: J.P. Crabbe, C. L. Frank, W. W. Nye
In the face of a changing health care system and increased competition, radiology departments need to become more efficient. One measurement of efficiency is promptness in producing a final report. Many large radiology centers have radiology
information systems (RIS) that track work flow, collecting tremendous amounts of data. Most, however, lack an appropriate analytic mechanism. We have developed an integrated system that allows continual monitoring of radiology work flow and thus of opportunities to apply interventions. This system can form an important component of the quality management process in the radiology department.
 In developing the system, we identified seven key steps in the work-flow process. When left to chance, these steps occur out of sequence and large delays occur. A scheme was devised to improve the sequencing of ıhe work flow by using the data collected from the RIS, sorted by radiology division and patient type. Biweekly, the appropriate data file is transferred to each division for analysis, via the department’s
computer network A one-step process follows, using desktop Macintosh computers and a custom program written in Microsoft Excel. Extracted data are quickly converted into a tailored division summary, and a report is automatically generated.