Quality needs to be viewed as part of a holistic system which includes multiple stakeholders, including individual health service providers as well as patients or clients who make use of health service processes. The effectiveness of quality measurement is to a large extent dependent upon the availability of information, prior knowledge of all concerned, and its application. The degree of health service delivery excellence needs to be considered within the context of one’s nursing and national health ecosystem, including any number of limitations influencing individual and overall staff performance within the workplace. Performance measurement programs, and the use of results obtained, are dependent upon purpose, leadership styles, organizational cultures, the use of standard data, chosen performance indicators/outcome measures, validated performance/quality measurement tools, and data analytics. The adoption of Lean and Six Sigma tools is indicated when there is a desire to improve overall efficiencies by streamlining the delivery of health services, patient journeys, and information and communication flows by reducing variation, waste, and cycle time. These activities benefit greatly from people with entrepreneurial mindsets. We have adopted a patient-centered caring philosophy as a prime value that can only be provided with the use of a collaborative approach to service delivery adopting a joint intellectual effort. These values influence the purpose and benefits of quality measurement programs. This chapter explores these concepts in some detail. Should quality be measured in terms of overall health service performance? Braithwaite argues that the key measures of health system performance have not changed for decades. He notes that 60% of care is based on evidence or guidelines that the system wastes 30% of all expenditure, and that around 10% of patients experience adverse events (Braithwaite, 2018). Quality is a concept that can also be applied to any healthcare service or nursing activity. There are many workplace limitations influencing staff performance over which they have little or no control. Quality measures, including Lean and Six Sigma, can apply to any situation or activity or procedure or system but these must be assessed in context. For example nursing models of care operationalize the constructs of nursing practice (Bender, Spiva, Su, & Hites, 2018) but this is dependent upon available resources including staff skill mix. Similarly nursing documentation is a high-level activity that pertains to many subsequent nursing practices and patient outcomes. The quality of patient and nursing documentation, along with its accessibility and its use, influences the quality of nursing practice. One review (De Groot, Triemstra, Paans, & Francke, 2018) found a lack of alignment between evidence-based quality indicators of documentation and the nursing process. It did identify the importance of the use of standard terminologies and user-friendly formats and systems as precursors for high-quality nursing documentation. Another review found some evidence that the adoption and use of electronic nursing documentation promoted or improved the quality of care and patient safety in acute hospital settings (McCarthy et al., 2018). These examples demonstrate that quality is about measuring the result of any activity or process undertaken by any individual as well as by the workforce as a whole. In the United States the value concept applied to clinical practice tends to be about evaluating the benefits of healthcare interventions relative to their cost. This may have ethical implications (DeCamp & Tilburt, 2017). Quality is about measuring the return on investments made not just in dollar or quantitative terms but also in qualitative terms. There are many confounding variables that independently and collectively influence the quality of healthcare services delivered that needs to be perceived in terms of cause and effect, performance outcomes, or productivity; it is about optimizing the output-to-input ratio. Productivity applies to any business or industry or an economy as a whole. It is therefore essential to consider all resources used (input), processes or activities undertaken to create a change, and what was achieved (output). Large and complex operational processes can and should be broken down into many smaller and simpler processes in an effort to better understand the bigger picture. Leaders and managers are instrumental in raising productivity and quality. Managers are responsible for obtaining the facts, planning, directing, coordinating, controlling, and motivating staff in order to produce any health service. They need to ensure that all resources needed (input) to undertake the service delivery processes are made available at the right time and place. The health workforce needs to apply the right knowledge and skills to ensure that every process is undertaken correctly and that available resources are used appropriately. Lean and Six Sigma activities apply to all such processes. Nursing work environments are complex. Many factors influence the demand for nursing services. Nurses need to work and deal with numerous stakeholders as well as care, treatment, management, and administrative concepts that collectively make up their ecosystem. An ecosystem essentially refers to the complex and interconnected organizational systems and services that collectively create the workplace “atmosphere” or culture that directly influences staff’s ability to be productive. It is about people and cultures that create or impede opportunities for the identification and implementation of Lean and Six Sigma activities. These need to be supported by suitable systems and procedures. Leadership styles and managers at various levels within any healthcare organization, along with workers, influence the “vibes” that create the overall ecosystem in either positive, inspiring, engaging, and supportive, or negative noncollaborative, organizational cultures. A collaborative workplace is paramount in being able to successfully implement and achieve the benefits of adopting Lean and Six Sigma principles. Nursing and midwifery workplace ecosystems constitute a significant resource input factor. A nursing ecosystem concept model as shown in Figure 20.1 incorporates the patient-centered level perspective and a patient outcomes level perspective within the holistically integrated four levels of the healthcare system. • FIGURE 20.1. Three Caring Concepts Defined Nurses face a challenge to translate rapidly increasing health knowledge, regulation, and quality patient care into professional activities. Ecosystem-wide dimensions and influencers of quality, including informatics, entrepreneurial mindsets, professional practice, standards, technology, education, culture, ethics, collegiality, teamwork, and the adoption of collaborative approaches, providing rich areas for nurses to identify new opportunities for adding value to the delivery of healthcare and patient satisfaction. This enables the incorporation of a “lived” culture of compassion, care, excellence, and professional practice in the delivery of nursing services in accordance with nursing process principles. Patients can play an important role in co-creating service value as they influence service provision by information seeking and sharing, interacting with the care and treatment processes, and providing feedback. Such patientcentered information may then be used to improve the quality of services provided (Zhang et al., 2015). Patient satisfaction is directly influenced by the care received throughout their interactions with health service providers and needs to be measured. Caring is person centered, it is about interpersonal behaviors of all healthcare team members responsible for supporting meaningful communication with the person of interest, their family, and/or their significant others. Three caring concepts were defined following extensive research (Strachan, 2016) as presented in Fig. 20.1. These definitions provide useful criteria for the identification or development of suitable patient satisfaction measurement instruments. Effective workforce management at every level, including education, workforce planning, and working conditions, is the precursor to any member of staff’s ability to exhibit these caring behaviors. Quality programs need to include the use of a variety of tools, including Lean and Six Sigma, to evaluate performance according to the following six quality dimensions (IOM, 2018): • Safety: Avoid harm. • Effectiveness: Avoid overuse of inappropriate care and underuse of effective care. • Person-centeredness: respectful of and responsive to individual preferences, needs and values that must guide clinical decisions. • Accessibility, timeliness, and affordability: Avoid harmful delays, and reduce access barriers and financial risk for patients, families, and communities. • Efficiency: Avoid waste, and make good use of available resources. • Equity: Provide the same quality of for all, irrespective of gender, ethnicity, race, geographic location, or socio-economic status. The Lean philosophy is about increasing efficiency by eliminating defects and streamlining work processes. This philosophy is often coupled with the terms “Thinking,” “Management,” or “Methodology.” “Lean” aligns with the New Zealand Health Strategy which calls for nurses to work using a “smart system” to streamline the delivery of health and the use of health information(Ministryof-Health, 2016). The Six Sigma concepts are also about reducing defects and variations in processes. When combined, the “Lean and Six Sigma” can be seen as a problemsolving approach to improve operational efficiencies (performance) and effectiveness (quality). Lean and Six Sigma has a good fit with the use of an innovation collaborative. A number of tools have been developed and are in use by cross-functional teams to facilitate continuous improvements using lean management principles. One in common use is the 5S methodology: Sort, Straighten, Shine, Standardize, and Sustain (Witt, Sandoe, & Dunlap, 2018). The Lean and Six Sigma problem-solving approach is often implemented using five steps: Define, Measure, Analyse, Improve, Control (DMAIC). The American Society for Quality (ASQ) promotes the use of Lean and Six Sigma to improve patient safety by eliminating life-threatening errors and addressing inefficiencies. ASQ offers a certification service and defines Lean and Six Sigma as follows: … a fact-based, data-driven philosophy of improvement that values defect prevention over defect detection. It drives customer satisfaction and bottom-line results by reducing variation, waste, and cycle time, while promoting the use of work standardization and flow, thereby creating a competitive advantage. It applies anywhere variation and waste exist, and every employee should be involved. (ASQ, n.d.) The application of “Lean” is often most visible within everyday nursing care as optimization of resources, a focus on waste reduction, or removal of unnecessary work through continuous improvements and workplace reorganization. “Six Sigma” emphasizes the reduction of variation and the adoption of standard procedures and is often associated with the use of statistical data analysis, design of experiments, and hypothesis tests (ASQ, n.d.). Although the terms “Lean” and “Six Sigma” are relatively new terms to many nurses working in everyday practice, it applies extensively to researched fundamental theoretical underpinnings that have been well documented since the 1950s. These theoretical foundations have remained constant and resulted in newly labeled applications and techniques previously referred to as “work study,” “industrial engineering,” or “operational research” approaches and methodologies (Barnes, 1980; ILO, 1979; Zandin, 2001) that were applied by Toyota resulting in their “Lean” approach. When applied to any industry it requires the identification of input, process, and output factors that collectively determine productivity, which, in turn, relates to Donabedian’s Structure-Process-Outcome theory. The Lean and Six Sigma processes can be implemented and measured using various levels of detail while the underpinning process remains constant, in that the measure of quality represents the output factors related to the input and change processes that were applied. For instance, an outline process flow chart or a swim lane diagram can be utilized to map a sequence of critical events and assist in visualizing a work or communication or data/information flow. The framework provided by such a process chart can form the big picture from which individual processes detailing significant operation/activity, such as bottlenecks or delays, can be identified as requiring more detailed investigation. It is about the levels of detail. Patient/client health journeys through the health system tend to be unique for every individual. Admission to any health facility is dependent upon any number of factors. Data and information are collected at various points along anyone’s health journey. Each journey consists of interactions at various (one to many) points of care with any number of members of the health workforce and healthcare facilities over any period of time. Along this journey one needs to consider demographic, clinical information, and communication flows to ensure care continuity. This is one area where the adoption of Lean and Six Sigma techniques can be most beneficial. Figure 20.2 shows how these productivity concepts can be applied to nursing (Hovenga, 2019). The output factors are the result of both overall organizational performance and the quality of individual services delivered. • FIGURE 20.2. Nursing Work Context (Hovenga, 2019). Copyright © Elsevier Mapping critical events in this manner can also be referred to as “Value Stream Mapping” (VSM), a leanmanagement method used for analyzing, documenting, and streamlining current operational processes. This methodology is no different to undertaking “system” or “business” analysis activities and is often likened to flow charting a workflow, a well-known technique used by Health ICT professionals. Furthermore, while numerous charting and mapping techniques or methodologies are available, each with their own set of symbols used for diagrammatic purposes, it is important to primarily focus on the theoretical underpinnings rather than the latest or trendy terminology in use. According to the International Labor Organization (ILO, 1979), work may be quantified in terms of the time that is required to perform any work activity. Work essentially consists of productive work and inefficiencies as listed in Fig. 20.3. Such inefficiencies impact upon healthcare’s operational effectiveness (output factors). These inefficiencies are areas any Lean and Six Sigma methodology needs to focus on in order to eliminate or minimize ineffective performance outcomes. • FIGURE 20.3. Productive Work and Inefficiencies There are a series of questions to ask about each process/activity in terms of purpose, place, sequence, person, and means, with a view to identify DOWNTIME (Defects, Overproduction, Waiting, Nonutilized Talent, Transportation, Inventory, Motion, and Extra-processing). The information gathered can then be used to eliminate, combine, rearrange, or simplify an activity. These questions are as follows: • What is the purpose and what is achieved? (value proposition) • Why is the activity necessary, what else could or should be done? • Where is it being done, why in this location, where else might it be done, where should it be done? • When is it done, why at that particular time, when could or should it be done? • Who is doing it, why that particular person, who else could or should do it? • How is it being done, why is it being done in that particular way, how else could or should it be done? Systematically posing these questions about every process/activity not only assists reflection, learning, and the adoption of evidence-based practice, it is essentially the first step toward problem solving and can be applied to any industry. These questions can be posed by any manager/supervisor at any time to enable the person undertaking the activity to reflect. It is common for people to simply say, “we’ve always done it this way.” New solutions should not lead to unintentional adverse consequences that may be the result of dysfunctional people behaviors or noncompliance with professional codes of conduct, or due to unethical practices, a lack of knowledge, and/or interpersonal skills. In a digital health ecosystem, information is stored in one of many types of digital formats which may or may not be accessible from any device by those who need to make use of it and who have authorized access to facilitate continuity of care and minimize the risk of delayed care. An analysis and mapping of data and information flows tends to identify areas of shortcomings where changes can make great improvements to reduce costs and improve operational efficiencies. This process enables the identifications of summary data required at various points of decision making throughout a patient’s health journey. This knowledge forms a useful basis for designing information system dashboards where data from multiple sources are presented on one screen to assist decision making at any level within the healthcare facility. Organizational cultures determine the values and observable patterns of behavior that influence the decisions made, the service delivery processes, and performance outcomes. The focus of Lean and Six Sigma techniques is on working together, in a joint intellectual effort to establish an “innovation collaborative.” Opportunities are central to the triggering of entrepreneurial and innovative behavior to streamline progression toward prototyping, objective validation, resourcing development, and gaining acceptance in the working environment of the healthcare ecosystem to solve problems and seek solutions. Cocreation is a resource integration process involving actors who are linked within a service ecosystem and who share recognized opportunities or value propositions as well as their resources for collaborative activities and interactions (Frow, McColl-Kennedy, & Payne, 2016). An alternative is the use of an innovation collaborative management process (Hazelton, Gillin, Kerr, Kitson, & Lindsay, 2019) to deliver quality-valued outcomes. Both healthcare and social entrepreneurship require the investment of scarce resources to achieve strategic future returns, not only to benefit patients but also all taxpayers (funders) and potential users of the healthcare ecosystem. This new paradigm of a “living” collaborative, as contrasted with laboratory research and testing, places the emphasis on a “person-centered” perspective rather than on the perspective of testing, controlling, and experimentation in a “laboratory” or clinical trial context. This requires the inclusion of health professionals and health users in the codesign of projects with personnel from all nursing ecosystem sectors. The above innovation collaborative concept may be described as a managed ecosystem engaging user communities yet retaining some form of control over the outcomes by the participating core organizations (Altman, Nagle, & Tushman, 2019). Traditional views of governance for healthcare management focus on the concepts of an established authoritybased hierarchy where any innovation activities resulting from Lean and Six Sigma applications are associated within the boundaries of the organization and where the concentration of control is high. An alternative consensus-based hierarchy model of governance, which supports knowledge transfer (Nickerson & Zenger, 2004), remains inside the organization, yet the concentration of control within the organization is more distributed and more appropriate for “searching solution spaces.” Indeed, the drastic reduction in information costs and the power of informatics provides a classic means to enhance innovation and deliver high value-added benefits to patients and healthcare users. Figure 20.4 demonstrates this symbiotic relationship for the utilization of informatics/information uptake across organizations and users of the nursing ecosystem. • FIGURE 20.4. Quality Ecosystem in Context of Control and Informatics/Information. (Adapted by Hazelton and Gillin from Altman, E. J., Nagle, F., & Tushman, M. L. (2019). Managed ecosystems and translucent institutional logics: Engaging communities. In terms of “concentration of control,” the consen sus-based, patient-centered mode (lower left quadrant) allows staff to take more responsibility (less concentration of control) of decisions around observed opportunities and achievement of the desired outcomes. However, both these modes of governance indicate a dependence on internal locus for use of informatics/information. In the context of recognizing broader application of opportunities and value-based problem solving, access to the relatives/community user market (lower right quadrant) determines the path of search by decentralizing control to those in possession of valuable, specialized knowledge. This access to the broad external resources of informatics/information still enables the staff to operate more democratically but within the boundaries of the organization. Activities associated with new knowledge, quality performance, and innovation (upper right quadrant) from the external community through an innovation collaborative network enable these independent organizations to provide guidance, orchestration, and/or help to value-adding outcomes that are not accounted for in the traditional hierarchy versus user market dichotomy. Context of control is about organizational structures, hierarchies, status symbolisms as identified by position titles, roles, boundaries of practice, mutual respect or its absence, collaboration versus competition, teamwork, including multidisciplinary teams, agreed values, and the degree of compliance to these values by individuals. It is critical to align processes, workflows, and organizational systems with the desired values and culture and to have a method that reinforces and sustains that to ensure positive experiences for patients/clients as well as all workers/employees. The adoption of collaborative infrastructures, cloud computing, mobile applications, and other digital technologies is key to facilitating work transformations requiring new and innovative organizational workplace design concepts. A vibrant digital workplace ecosystem enables productivity improvements to be realized while enhancing overall patient/client and workforce satisfaction. Decisions tend to be highly influenced by the most highly regarded values of the decision maker. Performance measures have been found to induce a range of unintended and dysfunctional consequences, including breaches of trust such as gaming misinterpretation (Mannion & Braithwaite, 2012). Impediments to change include entrenched bureaucracy, deep-seated politics or cultures where attempt to change these are seen to be superficial, or a lack of support from those in positions of power to resist or reject change (Braithwaite, 2018). All performance failures need to be addressed by adopting a continuous improvement quality program including the use of Lean and Six Sigma principles and tools. Lean and Six Sigma practitioners are able to make use of the Failure Mode and Effects Analysis (FMEA) tool, a systematic, proactive method used to identify potential risks, likely impact and causes. The results are usually presented within a spreadsheet. This enables them to explore and develop new preventative and/or minimization strategies. From a nursing perspective, it is important to be able to identify those outcomes that are known to or are likely to have been impacted by nursing service performance. The nursing profession needs to ensure that the relevant nursing data are routinely collected for operational use in a manner that enables not only the identification of nursing workload demand but also the collection of practice-based evidence. This requirement is fundamental for any health service as this enables a service to publish the evidence relevant to its capacity to care. Local activities need to be designed to benefit local stakeholders. Ideally, local quality programs are also able to contribute to the measurement of national health service performance for which indicators usually relate to policy and/or funding strategies. There have been a number of studies that identified adverse events representing unintended and at times harmful occurrences associated with the use of medicines, equipment, or various health service practices employed, including associations with staffing levels and skill mix (Butler et al., 2011; Kohn, Corrigan, & Donaldson, 2007; Olley, Edwards, Avery, & Cooper, 2018; Spence Laschinger & Leiter, 2006; Van den Heede, Clarke, Sermeus, Vleugels, & Aiken, 2007). A variety of outcome metadata is in use, including the data used for statistical reporting such as the International Classification of Diseases (ICD), a classification system that differs from a reference terminology. Patient outcomes essentially represent the results of a new patient assessment at a later point in time to determine change in a patient’s health status. Patient outcomes are influenced by any type of adverse event such as missed nursing care, and near misses. These events incur unnecessary additional costs to both health service providers and patients. Such events influence the length of hospital stays and contribute to unnecessary patient discomfort due to delays or complications. The U.S.-based Patient-Centered Outcomes Research Institute (PCORI) (PCORI, 2018) focuses on funding projects designed to improve care and outcomes for patients living with high-burden health conditions. It is about helping patients and those who care for them make better informed decisions about healthcare choices. It is critical for the nursing profession to contribute and gain new knowledge from these initiatives by ensuring that the capacity to contribute nursing data exists. (Brennan & Bakken, 2015). For example, nursing diagnosis data were found to have an independent power in predicting hospital mortality (Sanson et al., 2019). The nursing profession needs to ensure that it is able to collect such data and make their contributions to human health visible. These transformational activities have major implications for nurse leaders (Westra, Clancy, et al., 2015). Making a difference requires not only the right data reflecting performance indicators but also collaboration, teamwork, collegial cultures, and entrepreneurial mindsets. Collegial cultures refer to work environments where responsibility and authority are shared equally by one’s colleagues. This determines the collective mindset that differentiates professional contributions to patient and organizational performance outcomes. It is about value systems, multidisciplinary teamwork, interdisciplinary teamwork, mutual respect of the relevant discipline’s knowledge, and contributions to satisfactory outcomes. Collegiality emphasizes trust, independent thinking, and sharing between coworkers. It is an important aspect of effective teamwork which contributes significantly to the quality of care delivered. Accountability is a crucial part of collegiality as nurses are answerable to each other for their collective practice (Padgett, 2013). Collegiality was found to influence missed nursing care, along with other factors traditionally defined to make up the nursing practice environment (Menard, 2014). As a major contributor to the quality of nursing services delivered, collegiality needs to be included as a performance measure. Entrepreneurship is now a topic of conversation in the broader domain. Entrepreneurial leadership generates an entrepreneurial culture supporting innovative developments. An “entrepreneurial mindset” is able to identify opportunities for change that surface in organizations’ internal and external environments and commit, make decisions, and act to pursue them, especially under conditions of uncertainty that commonly accompany rapid and significant environmental changes. When nurse leaders adopt an entrepreneurial mindset, organizational actors increase their ability to sense opportunities and mobilize the resources and knowledge required to exploit them. Being entrepreneurial is essentially about thinking and doing something not done before, in order to achieve a desirable goal or outcome. It is about assessing a situation, designing alternatives, and choosing a new way, the Lean and Six Sigma approach, which may lead to something better. Such professional healthcare practice results from applying the nursing process, data acquisition, and analysis to exploit opportunities, solve problems, and deliver solutions. An entrepreneurial mindset is not achieved by writing business plans. It requires the development of personal attributes and behaviors associated with this approach and pursuing them with passion and commitment, seeking necessary physical, human, and financial resources to “make-it-happen.” Table 20.1 illustrates how the practice of an entrepreneurial mindset within an organization can add effective benefits to six-sigma programs operating within a healthcare system. TABLE 20.1. Six Sigma Benefits and Added Benefits from Entrepreneurial Mindset (Hazelton et al., 2019)
20
Using Six Sigma and Lean for Measuring Quality
ABSTRACT
WHAT IS QUALITY?
NURSING WORK ECOSYSTEM
Patient-Centered Care
QUALITY PROGRAMS
“Lean” and ‘Six Sigma Techniques”: Why Apply These to the Health Industry?
Cocreation or Innovation: A Collaborative Approach to Service Delivery
Performance Outcome Measures and Data Collection Tools
Collegial Cultures
Entrepreneurial Mindsets
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