Public health is tackling a broad range of challenges, from smoking, obesity and alcohol abuse to mental and sexual health. While the majority of public health departments and community-based healthcare providers are racing to meet the Healthy People 2010 objectives, disasters such as Hurricane Katrina have brought concerns related to a lack of systematic processes to the forefront. Furthermore, with continual decline in federal and local funding to address these issues, public health administrators are focusing on finding novel solutions to meet the needs of their communities.
Key stakeholders in public health recognize that now is the time for innovative and fresh thinking in improving and supporting healthier communities. The time is right to find better, data-driven solutions to improve operations, to develop a skilled and motivated workforce, and to improve health outcomes of their constituents. Implementing continuous improvement methodologies can create a clear path for solutions that will have a positive outcome. Such methods help to identify opportunities for improvement, highlight non-value-added steps and organize the workplace for peak efficiency.
Case Study: Addressing Improvement Areas in Public Health
To address the needs and gaps within the arena of public health, some departments are implementing the principles of Lean Six Sigma. The Marion County (Ind., USA) Health Department (MCHD), for example, has taken steps to bring Lean Six Sigma into its public health clinics, including awareness training to senior leadership and identification of four improvement areas:
- Community health
- Customer satisfaction
- Workforce efficiency
- Financial savings
The overall goal of one MCHD health clinic in Indianapolis is to reduce the prevalence of sexually transmitted diseases (STD). In order to meet that goal, clinicians need to see as many patients as possible within maximum defined wait times while maintaining best practices. Before improvement, the clinician process was only capable of seeing 1.1 patients per hour, with a patient length of stay (LOS) that exceeded 120 minutes. The performance metrics from the time are listed in the table below, while the process steps of a patient visit are shown in the figure below.
| Performance Measurements for Clinic Before Improvement | |||
| Metrics | Current | Std. Dev. | Goals |
| Number of full-service patients per hour | 1.1 patients/hour | 0.3 patients/hour | 2.5 patients/hour |
| LOS at clinic | Less than 120 minutes | 23.4 minutes | Less than 60 minutes |
The Kaizen Event
A Lean Six Sigma team was formed for a five-day Kaizen event utilizing the DMAIC (Define, Measure, Analyze, Improve, Control) methodology and Lean tools.
The team began the Measure process by mapping out the current process using both a value stream mapping technique and a spaghetti map to better understand patient, clinician and information flows and cycle times. The team collected and validated cycle-time data, as well as patient and clinician travel distance by number of steps, for analysis. They conducted a value analysis to determine and define activities as customer value added, business value added or non-value added. Through this analysis, the team found that less than 2 percent of activities were considered to be customer (the patient) value added.
Two quick wins were identified by the value analysis that eliminated 18 minutes in the patient flow:
- Patients with an appointment no longer went through triage.
- Patient forms were revised, eliminating obsolete and redundant information.
By analyzing the remaining data, the team determined that the two areas impacting patient flow were triage, and the clinician diagnosis and treatment process. The actual cycle time for these two processes was 55 minutes, with a patient wait time of 82 minutes. The team’s primary focus was to identify and validate the root cause for patient flow inefficiencies within these two primary areas.
In the Analyze phase, the team performed a fishbone analysis that identified three main areas as potential root causes:
- Patient turnaround time
- Data entry
- Lack of clinician teamwork and skills
The team gathered data and used it to validate these three areas by performing hypothesis testing through analysis of variance (ANOVA).
Patient turnaround time – ANOVA compared clinicians who saw at least two patients in parallel against clinicians only seeing one patient at a time. Results: Clinicians seeing patients in parallel had a significant time impact on reducing patient time and capacity.
Data entry – ANOVA compared computer data entry versus manual entry of data on the patient form. Results: Manual data entry had a significant time impact on reducing patient time and capacity.
Clinician teamwork and skills – Developing an employee skills proficiency matrix, the team analyzed clinicians who were more skilled or knowledgeable than other clinicians. Results: Clinicians who were more proficient had a significant time impact on reducing patient time and capacity.
Moving Forward
The clinician improvement team reduced patient LOS by 63 minutes. Because clinicians came up with the solution of seeing patients in parallel, they were more easily able to gain buy-in for this change. Other solutions included using a manual check list form (color-coded for male and female) and a skills proficiency matrix to improve teamwork and overall competence, which led to positive outcomes in identifying diseases.
The clinicians’ patients per hour metric improved immediately to 2 patients per hour with the parallel patient flow, and over time, as clinician skills and teamwork improved, reached the original goal of 2.5 patients per hour. The clinicians began meeting for 10 to 15 minutes each morning to review their own dashboard, workload, and document and status issues. This Kaizen event also led to the establishment of a monthly meeting of the clinic leadership team and the clinicians. These meetings were designed as a time to review strategic goals and evaluate their efforts on identifying and reducing the prevalence of STDs in the community.
The STD clinic will be moving to a new facility in 2012 and the spaghetti mapping will be of significant support for the facility layout to reduce walking for both the clinicians and patients. In addition, the cumbersome and time consuming computer system is expected to be overhauled with input from the clinic personnel to eliminate paper forms.
Breakthroughs in Public Health
As seen in the case study, Lean Six Sigma is a rigorous and disciplined approach to problem solving and culture change. Implementation of Lean Six Sigma’s principles in the field of public health will enable organizations to develop effective models to improve their operations, deliver care effectively and efficiently, and create positive health outcomes within their community.
