A realist evaluation of the contribution of Lean Six Sigma to person-centred cultures in a university hospital

Background: Lean Six Sigma, a quality improvement methodology, has been used in healthcare since 2001. Person-centred approaches to healthcare improvement are now widely advocated in political, policy and practice discourse. Literature shows quality improvement practitioners are often unaware of or pay little attention to Lean Six Sigma’s philosophical roots, seeing it less as an organisational philosophy but more as a quality improvement tool for continuous improvement. A lack of fidelity to Lean Six Sigma’s philosophical roots can create a division between person-centred approaches to transforming care experiences and services, and quality improvement methods focusing solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which Lean Six Sigma education influences healthcare staff’s person-centred practice. Aim: To address the question: whether, to what extent and in what ways, Lean and Six Sigma in healthcare contribute to person-centred care and cultures. Design and methods: Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) that explained how Lean Six Sigma influenced practice, relating to staff, patients and organisational influences. A realist evaluation explored how staff interacted with a Lean Six Sigma education programme (the intervention). Specifically, the CMOc relating to staff was adjudicated by study participants to determine whether, to what extent and in what ways it influenced person-centred care and cultures. Data collection was informed by person-centred principles and took place through a series of workshops and semi-structured interviews, followed by a review of research participants’ improvement projects outcomes. Findings: Three focused CMOcs, Aspects of Organisational Culture, the Organisation’s Receptivity and Participants’ Self-perception, emerged from the adjudication of the CMOc relating to staff, illuminating the contextual factors (C) that facilitated the outcomes (O) that arose from the underlying mechanisms (M) that were active when the contextual factors (C) were present. Synergies (respect for persons, voice of the customer, staff empowerment and observational studies), an influencer (quality) and divergences (core values, standardisation and first principles) between participants’ Lean Six Sigma practice and person-centred care and cultures were also revealed. Discussion: A return to Lean Six Sigma’s philosophical roots facilitates coherence in the philosophy, intention, methods and outcomes between Lean Six Sigma and person-centred approaches. Their combined use is not only possible but may also be desirable, enabling Lean Six Sigma practitioners to work in ways that support the development of quality, person-centred care that takes account of the outcomes for, and experiences of, patients, their families and staff. Incorporating person-centred principles into the research design, whilst adhering to the principles and rigour of realist evaluation, resulted in a new way of adjudicating CMOcs and novel methods of working with research participants. This study contributes to the evidence base on the study of quality improvement beyond the effectiveness of interventions alone. The findings will be of interest to researchers, policymakers and practitioners globally. Keywords: Lean, Six Sigma, Lean Six Sigma, Process improvement, Person-centredness, Person-centred care, Person-centred cultures, Kaizen

A discussion of the synergy and divergence between Lean Six Sigma and person-centred improvement sciences

Background: This paper discusses if and how the improvement sciences of Lean Six Sigma and person-centred approaches can be melded or blended in the health care context. The discussion highlights the relationship between each approach to improvement science in terms of their respective purposes, intentions and probable outcomes; positioning these as either synergies or divergences. Comparison of the key theoretical and methodological principles underpinning each approach to improvement is also considered and implications for future practice, policy and research are drawn out. The discussion is informed by part of the findings of a realist review of relevant literature.Conclusions: Lean Six Sigma as a process improvement methodology appeals to a wide range of stakeholders in healthcare internationally. Four key synergies and three key divergences between Lean Six Sigma and person-centred approaches were found. The discussion here highlights the need for further research into Lean Six Sigma implementation and its possible contribution to developing person-centred cultures.Impact: Adoption of Lean Six Sigma in health care by stakeholder groups, external to nursing, has been taking place. At the same time there has been a loss of Lean’s original intention of respect for people in favour of a technical efficiency focus on reducing waste and variation. Our findings of four key synergies and three key divergences between both approaches indicate where synergies can be maximised and divergence narrowed to improve implementation and enhance methodological coherence. Researchers, policy makers and practitioners should be aware that use of Lean Six Sigma alone may have a limited impact on developing personcentred care and culture. Use of Lean combined with person-centred approaches may appeal to a wider range of stakeholders. Yet, their combined use and effectiveness has not as yet been evaluated.This paper was supported by Queen Margaret University Edinburgh and University College Dublinhttps://doi.org/10.3844/ijrnsp.2020.10.2311pubpu

Making a Sustainable Difference to People, Processes and Systems: Whole-Systems Approaches to Process Improvement in Health Systems

From Crossref journal articles via Jisc Publications RouterHistory: epub 2023-03-23, issued 2023-03-23Article version: VoRPublication status: PublishedSeán Paul Teeling - ORCID: 0000-0002-4102-7280 https://orcid.org/0000-0002-4102-7280The eighteen papers in this Special Issue, ‘Whole-Systems Approaches to Process Improvement in Health Systems’, address an enduring challenge in healthcare: to improve efficiency with existing or reduced resources, while maintaining safe and effective care [...]pubpu

Using Lean Six Sigma in a Private Hospital Setting to Reduce Trauma Orthopedic Patient Waiting Times and Associated Administrative and Consultant Caseload

From Crossref journal articles via Jisc Publications RouterHistory: epub 2023-09-26, issued 2023-09-26Article version: VoRPublication status: PublishedSeán Paul Teeling - ORCID: 0000-0002-4102-7280 https://orcid.org/0000-0002-4102-7280In Ireland, the extent of outpatient orthopedic waiting lists results in long waiting times for patients, delays in processing referrals, and variation in the consultant caseload. At the study site, the Define, Measure, Analyze, Improve, and Control (DMAIC) Lean Six Sigma framework was applied to evaluate sources of Non-Value-Added (NVA) activity in the process of registering and triaging patients referred to the trauma orthopedic service from the Emergency Department. A pre- (October–December 2021)/post- (April–August 2022) intervention design was employed, utilizing Gemba, Process Mapping, and the TIMWOODS tool. Embracing a person-centered approach, stakeholder Voice of Customer feedback was sought at each stage of the improvement process. Following data collection and analysis, a co-designed pilot intervention (March 2022) was implemented, consisting of a new triage template, dedicated trauma clinic slots, a consultant triage roster, and a new option to refer directly to physiotherapy services. This resulted in the total wait time of patients for review being reduced by 34%, a 51% reduction in the process steps required for registering, and an increase in orthopedic consultant clinic capacity of 22%. The reduction in NVA activities in the process and the increase in management options for triaging consultants have delivered a more efficient trauma and orthopedic pathway.pubpu

A realist inquiry to identify the contribution of Lean Six Sigma to person-centred care and cultures

From MDPI via Jisc Publications RouterA lack of fidelity to Lean Six Sigma’s (LSS) philosophical roots can create division between person-centred approaches to transforming care experiences and services, and system wide quality improvement methods focused solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which LSS education influences healthcare staffs’ person-centred practice. This realist inquiry asks ‘whether, to what extent and in what ways, LSS in healthcare contributes to person-centred care and cultures’. Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) explaining how LSS influenced practice, relating to staff, patients, and organisational influences. Realist evaluation was used to explore the CMOc relating to staff, showing how they interacted with a LSS education Programme (the intervention) with CMOc adjudication by the research team and study participants to determine whether, to what extent, and in what ways it influenced person-centred cultures. Three more focused CMOcs emerged from the adjudication of the CMOc relating to staff, and these were aligned to previously identified synergies and divergences between participants’ LSS practice and person-centred cultures. This enabled us to understand the contribution of LSS to person-centred care and cultures that contribute to the evidence base on the study of quality improvement beyond intervention effectiveness alone.https://doi.org/10.3390/ijerph18191042718pubpub1

Developing new methods for person-centred approaches to adjudicate context−mechanism−outcome configurations in realist evaluation

From MDPI via Jisc Publications RouterRealist evaluation provides a general method of evaluating the application of interventions including policy, legislation, projects, and new processes in social settings such as law enforcement, healthcare and education. Realist evaluation focuses on what about interventions works, for whom, and in what circumstances, and there is a growing body of work using realist evaluation to analyse interventions in healthcare organizations, including those using Lean Six Sigma improvement methodologies. Whilst realist evaluation facilitates the analysis of interventions using both qualitative and quantitative research, there is little guidance given on methods of data collection and analysis. The purpose of this study is to address this lack of guidance through detailing the use of innovative person-centred methods of data collection and analysis in a realist evaluation that enabled us to understand the contribution of Lean Six Sigma to person-centred care and cultures. This use of person-centred principles in the adjudication of identified program theories has informed novel methods of collecting and analysing data in realist evaluation that facilitate a person-centred approach to working with research participants and a way of making the implicit explicit when adjudicating program theory.19pubpub

The use of Lean Six Sigma for improving availability of and access to emergency department data to facilitate patient flow

From MDPI via Jisc Publications RouterSeán Paul Teeling - ORCID: 0000-0002-4102-7280 https://orcid.org/0000-0002-4102-7280The aim of this study was to redesign an emergency department [ED] data management system to improve the availability of, and access to, data to facilitate patient flow. A pre-/post-intervention design was employed using Lean Six Sigma methodology with a focus on the voice of the customer, Gemba, and 5S to identify areas for improvement in ED data management processes and to inform solutions for improved ED patient flow processes. A multidisciplinary ED team includes medical consultants and registrars, nurses, patient service staff, radiology staff, as well as information technology and hospital management staff. Lean Six Sigma [LSS] diagnostic tools identified areas for improvement in the current process for data availability and access. A set of improvements were implemented to redesign the pathway for data collection in the ED to improve data availability and access. We achieved a reduction in the time taken to access ED patient flow data from a mean of 9 min per patient pre-intervention to immediate post-intervention. This enabled faster decision-making by the ED team related to patient assessment and treatment and informed improvements in patient flow. Optimizing patient flow through a hospital’s ED is a complex task involving collaboration and participation from multiple disciplines. Through the use of LSS methodology, we improved the availability of, and fast access to, accurate, current information regarding ED patient flow. This allows ED and hospital management teams to identify and rapidly respond to actions impacting patient flow.pubpu

Using a combined Lean and person-centred approach to support the resumption of routine hospital activity following the first wave of COVID-19

From MDPI via Jisc Publications RouterThe unexpected advent of the COVID-19 pandemic led to a sudden disruption of routine medical care, with a subsequent reorganization of hospital structures and of care. Case studies are becoming available in the literature referring to the logistical difficulties involved in a hospital resuming normal activity following the first COVID-19 lockdown period. This paper details the experience of a study site, a private hospital in Dublin, Ireland, in the redesign of service delivery in compliance with new COVID-19 prevention regulations to facilitate the resumption of routine hospital activity following the first wave of COVID-19. The aim was to resume routine activity and optimize patient activity, whilst remaining compliant with COVID-19 guidelines. We employed a pre-/post-intervention design using Lean methodology and utilised a rapid improvement event (RIE) approach underpinned by person-centred principles. This was a system-wide improvement including all hospital staff, facilitated by a specific project team including the chief operation officer, allied therapy manager (encompassing health and social care professionals), infection prevention and control team, head of surgical services, clinical nurse managers, patient services manager and the head of procurement. Following our intervention, hospital services resumed successfully, with the initial service resumption meeting the organizational target of a 75% bed occupancy rate, while the number of resumed surgeries exceeded the target by 13%. Our outpatient visits recovered to exceed the attendance numbers pre-COVID-19 in 2019 by 10%. In addition, patient satisfaction improved from 93% to 95%, and importantly, we had no in-hospital patient COVID-19 transmission in the study period of July to December 2020.19pubpub

A case study of a whole system approach to improvement in an acute hospital setting

From MDPI via Jisc Publications RouterChanges in healthcare tend to be project-based with whole system change, which acknowledges the interconnectedness of socio-technical factors, not the norm. This paper attempts to address the question of whole system change posed by the special issue and brings together other research presented in this special issue. A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement. The approach to change was co-designed by staff and management, projects involving staff from all specialities and levels of seniority were linked to each other and to the strategic objectives of the organisation, and learnings from first-generation projects have been passed to second and third-generation process improvements. The socio-technical systems framework was used retrospectively to assess the system change but could also be used prospectively to help healthcare organisations develop approaches to whole system improvement.19pubpub

The use of Lean Six Sigma methodology in the reduction of patient length of stay following anterior cruciate ligament reconstruction surgery

From MDPI via Jisc Publications RouterBackground: The purpose of this study was to reduce the length of stay of anterior cruciate ligament reconstruction patients within a private hospital in Ireland, reducing any non-value-added activity in the patient pathway, with the goal of increasing patient flow, bed capacity, and revenue generation within the hospital system, while maintaining patient satisfaction. Methods: We used a pre-/post-intervention design and Lean Six Sigma methods and tools to assess and improve the current process. Results: A reduction in inpatient length of stay by 57%, and a reduction in identified non-value-added activity by 88%, resulted in a new day-case surgery pathway for anterior cruciate ligament reconstruction patients. The pathway evidenced no re-admissions and demonstrated patient satisfaction. Conclusion: Six months post-project commencement, we had successfully achieved our goals of reducing our anterior cruciate ligament reconstruction patient’s length of stay. This study contributes to the growing body of published evidence which shows that adopting a Lean Six Sigma approach can be successfully employed to optimise care and surgical pathways in healthcare.19pubpub