Barriers that Lead to Unsuccessful Implementation of LSS in Healthcare - Example

Discussion of Barriers that Lead to Unsuccessful Implementation of LSS in Healthcare Institutions Name Institution Bureaucracy in Hospital Management Bureaucracy, in this case, can be defined as administration or management maneuvers marked by strict hierarchal authority amongst various offices, and often involving fixed procedures. The higher an individual is in the chain of bureaucratic command, the more that individual has authority to influence procedures and policies, which will be implemented by those lower in the chains of command. Most hospitals have a chain of command starting with the Board of Directors at the top most level, then comes the Chief Executive Officer, followed by the Medical director. Immediately below the named top executives come the vice presidents, whose responsibilities include the overseeing of most hospital functions, for instance, medical records, human resources, intensive care and surgery operations (Spear, 2005, p.78). Hospitals have a rather clear and rigid chain of command; a nurse, for instance, would never change the dosage of a patient in intensive care without direct orders from the involved physician, even though the patient was at the verge of death and clearly needed an increase or decrease of certain medication. This greatly slows down reaction times, especially given the fact that physicians spread their working time doing hospital rounds in two or more hospitals and the personal office practices (Mcgill, 1993, p.69). Yet, the direct care givers such as nurses have more contact with the patients, and are best placed to quickly respond to emergencies and change in patients’ conditions. Bureaucratic tendencies in hospitals affect other things, including: financial appropriation, service quality, team norms, normative controls and organizational culture. Financial control involves authorization to utilize hospital finances for any purpose, even if it is for very useful purposes, such as upgrading intensive care units. Quality controls dictate the standard acceptable variation in processes (Lucey et al., 2005, p.13). For instance, the standard patient registration can be quite time consuming and adversely expose the patient to risk. Poor laboratory results would lead to wrong diagnosis. Team norms, normative controls and organizational culture cover the written and unwritten procedures and policies governing managerial and employee behavior. In a case where an experienced informal leader has more influence than an appointed formal leader, friction will arise and implementation of LSS will suffer as result of the leadership bureaucracy. Hospital departmental heads are held responsible for maintaining expenses within the budget guidelines. The finances coming to a given department, therefore, are controlled by upper management. In the case where there is need to increase the capacity of an X-ray unit, improve the bed availability, increase laboratory results accuracy or increase the hospital’s surgical capacity, new equipment must be sourced and additional personnel hired. The availability of required funds and authorization to carry out these processes will be determined by upper management (Bisgaard, 2009, p.33). The improvements will not happen if an individual high up in the command chain does not want it. Usual improvement procedures take eons to approve and these results in frustration of hospital personnel and deterioration of service quality. For Lean Six Sigma to be implemented there must be uncompromising commitment and support from top level management. Recommendations 1. The upper management must support and be fully committed to the implementation of LSS 2. Creation of powerful multidisciplinary committees to monitor and ensure success of improvement effort despite of bureaucracy 3. Formulating flexible policies that empower lower level employees and grant nurses more autonomy in regards to responding to emergencies and identifying deficiencies. These include procedures which delegate responsibilities downward, such as Therapist Driven Protocols (TDPs) which build safety boundaries within which a therapist can interact with a patient in the absence of a physician (Kenney, 2010, p.40). Lack of Training George Eckes (2005) says that one of the main barriers to the successful implementation of LSS is the way in which the major LSS training providers structure their coaching offerings. He further points out that a main realization that organizations need to gain is the fact that Lean Six Sigma is not pegged on statistics, but rather statistical thinking. When an organization goes about hiring their LSS consultant, they should be careful to hire the best. In our case, the consultant should be conversant with hospital organizational structure and basic operating procedures. The successful implementation of improvements in any setting, in this case a hospital, must start with the top leadership. The chosen training consultant must begin by providing the senior management with coaching in the tools and principles they need, for preparing the organization towards successful improvement. Consequently, by utilizing this new knowledge, the top leadership will deliberately direct the successful acquisition and development of infrastructure required to support LSS (Brandaw, 2009, p.127). A simultaneous step should be taken to psyche up the organization and create an environment of creativity and innovation. This includes reduction of organizational hierarchy levels and termination of procedural barriers (Eckes, 2005, p.34). Failure to actively train the upper managers about their roles in this dispensation will spell doom to the process before it even starts. The next step should involve the establishment of close communication channels with hospital personnel, customers and suppliers. This will also include determining and evaluating employee, supplier and customer inputs. Additionally, base studies are carried out to identify policy, procedural, cultural and infrastructural obstacles to success, hence determining the starting point (Schweikhart, 2009, p.751). A team consisting of trained upper managers, the consultant, employees, suppliers and selected patients should come up with a list of typical areas that require improvement. LSS can be implemented in the following hospital processes: increasing the capacity of X- ray rooms, reduction of time taken to prepare medical reports, improvement of patient satisfaction in emergency room, reduction of bottle necks at the emergency department, reduction of medical errors, increasing laboratory results’ accuracy, reducing billing errors, improving availability of beds, reduction of post-operative infections, increasing the surgical capacity, reducing the inventory levels, improving registration accuracy of patients, reduction of duplicated information and reduction of unnecessary tests among others (Radnor, 2011, p.12-13). The team should also be coached on more diagnostic processes for future use to ensure future success; otherwise the consultant will keep on returning when improvements are needed. The selection the right personnel is critical in the implementation of LSS projects. Once the required infrastructure is in place, the upper management knows its role and success obstacles mapped out, training begins. The specific project champions are given a proper overview of LSS fundamentals and the needed skills for project prioritization, scoping and execution. The Black belts spend 4 weeks in intensive training, 1 week of every month for 4 months. The training is on execution of LSS type projects and the needed techniques and tools for problem solving. The Black belts are required to work on at least two LSS projects for certification. On the other hand, the Green belts get 2 weeks of intensive training. They are also required to select to choose a project from their processes of work (Arthur, 2011, p.72). Any deficiencies or gaps to this training package will result in implementation failure at some level. Recommendations 1. Training needs should be rigorously assessed. Remedial skills related to education should be offered to ensure adequate numeracy and literacy levels. 2. A Continuous improvement framework should be developed together with an indicator system to monitor progress and successful LSS training. Lack of Reliable Data Identifying the data required and the actual collection of the full data for LSS projects are important activities. The solutions to products and/or services that have failed to meet external or internal customer needs depends on the quantity and quality of the data available for that particular study. The process of collecting data can be quite tricky, especially in areas where there lacks measurable data, such as in the healthcare question of patient satisfaction. It is therefore paramount that the researcher spends enough time in the collection exercise and does it well by incorporating advanced techniques and supportive technologies (Breyfogle et al., 2001, p.17). Collecting too little or too much data is detrimental to the entire improvement agenda, so is collecting inaccurate data. The Measure step in DMAIC involves gathering information concerning the ineffective processes that need improvement. As such, there are many tools that can be used in determining the impact of a problem. Smart leaders try and enlist the interactive support and involvement of the people who have encountered first-hand the particular problems in question, for the process of collecting data (Sehwail & De Young, 2003, p.4). In a hospital setting, when addressing a problem such as the X-ray room capacity, the best person to help in data collection is the radiologist. If it is a question of patient satisfaction, the patients, nurses and physicians should be intimately involved in collecting the data. Failure to do so will only lead to inaccurate data and hence compromise the LSS implementation in that particular facility. The next phase is analyzing the collected data. This means that statistical tests are applied on the data so as to confirm the existence of the suspected problem, and hence help quantify this problem. In a healthcare setting, four groups of response variables or metrics are used to define system performance. They include service cost, service level, customer satisfaction and clinical excellence. Service level indicates ability of system performance in meeting the expectations of physicians, patients and various other stakeholders. Each metrics set contain specific parameters. For instance, indicators at the service level can be generalized as wait time, access to good care, information convey time and service time. Indicators of service cost could include labour productivity and cost per service unit. Indicators of customer satisfaction can be put in groups, for instance, referring physician, family, nurses, payer and patient. Indicators of clinical excellence may be related to particular pathways of treatment, for instance, compliance with a given prescription (Lanser, 2000, p46-47). Many healthcare institutions measure performance by combining some of the said four groups. However, such analysis can be often misleading since these metrics usually represent an average. It is factual that customers rarely get to experience average performance of a given system; they tend to mostly experience the variability. Additionally, patient care usually involves a human element compared to machine operations. For this reason, variability is difficult and subtle to quantify (Chow-chua & Goh, 2000, p.29). In any case, the data collected and analyzed in certain human-influenced aspects is largely incorrect, or a mean of the actual value. As such, one of the main challenges to adopting LSS to healthcare is finding a means to leverage data from LSS to drive change in human behavior, a herculean task. Other reasons for data inaccuracy include: personnel negligence, poor training, poor analysis methods, poor statistical technology and systems (Breyfogle et al., 2001, p.25). Recommendations 1. Leveraging of new data collection and analysis hardware and software. 2. Proper training of personnel on data collection and analysis. Corruption As a locus of a big proportion of total health expenditure – and considering their complexity and size, hospitals offer a myriad of opportunities for corrupt activities, as Vian and his colleagues observe (Vian et al., 2005, p.5). Money usually leaks from healthcare facilities via opaque procurement procedures of supplies and equipment, exaggeration of construction costs, ghost workers and inflation of service prices. In developing nations, one of the results is the depletion of budgetary allocations for other required health services such as basic or primary health care programs. At every turn, it is patients who suffer, since they are coerced to pay bribes for crucial health services and also because many treatment decisions and procedures are pegged on financial motivations, other than the patients’ medical needs (Balakrishnan et al., 1999, p.21). In economics, corruption is regarded as a ‘crime of calculations’ which will likely occur where there are large budgets and high possibilities for monetary gains from official decisions. Hospitals do meet this criterion for high vulnerability. Typical large hospital spending includes purchasing equipment and new technologies, labour costs and building constructions. The need for managing many stakeholders (patients, doctors, administrators, procurement specialists, accountants, clinicians, nurses and other personnel) of different interests additionally creates a corruption susceptible environment (Becker et al., 2005, p.7). All corrupt activities in a hospital will undermine successful implementation of LSS and should, in fact, be targeted as LSS projects. Theft of medical supplies by hospital personnel causes needy patients to lack medications, hence reduced patient satisfaction. Dubious payments cause anxiety and access to proper care is reduced. As hospital resources drain from allocated budgets via procurement fraud and embezzlement, lesser funds will be available to fund operations and pay wages (Savedoff, 2006, p.33). Actually, this means that any LSS projects underway will be channels for further embezzlement and hence defeat the very purpose of improvement set out. All this leads to de- motivation of staff and increased absenteeism as disgruntled personnel seek extra income in other outside jobs (Gruel et al., 2002, p.9). This again lowers access to services as well as decreases their quality. Any LSS project carried out under such circumstances will result in mediocre results if not outright failure. An in-depth description of corrupt practices that will ultimately compromise LSS projects in a hospital is as follows (Savedoff, 2006, p.35): 1. Overpayment of services and medical goods which involves engaging in bribes, collusion and kick-backs in the procurement process, hence overpayment for services and procured supplies 2. Embezzlement, which involves diverting user revenue and budgetary funds for personal use 3. Theft, which involves stealing medical equipment and medication for personal uses, re-sale or private practice 4. Absenteeism, which involves failure to show up for work and working fewer hours 5. Informal payments, which involve extortion and dubious payments for treatment and special privileges 6. Abuse of resources, that is, the use of hospital vehicles, space and equipment for personal advantage 7. Favouritism in hospital billing which includes fee waivers and falsification of insurance documents 8. Sale of accreditation and positions, which involves extortion and bribes in influencing hiring, licensing and certification 9. Illegal referrals and performance of unnecessary treatment/medical procedures. Recommendations 1. Including corrupt or fraudulent activities as LSS projects 2. Engaging the top level management about corruption effects in the organization 3. Incorporating technologies that minimize monetary fraud and monitor quantifiable corruption References Arthur, J. (2011). Lean Six Sigma for Hospitals: simple steps to fast, affordable, flawless healthcare. New York: McGraw-Hill. Brandao de Souza, L. (2009), Trends and approaches in lean healthcare, Leadership in Health Services 22(2), 121-139. 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