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Healthcare Performance Improvement Mistakes, Part 8: Performance Improvement Is A Part-Time Job

Submitted By: Brian MacClaren

Implementing a focused and structured program for healthcare performance improvement is a huge step that requires a great deal of thought and numerous decisions. One of the most difficult decisions seems to be whether or not to dedicate full time resources as practitioners. In the resource constrained environment that most healthcare organizations operate in, there is a natural tendency to expect your practitioners to drive improvements in addition to their real job.

The degree of rigor imbedded into modern process improvement methodologies for healthcare such as Lean and Six Sigma makes this expectation of multi-tasking short-sighted. The components that need to be considered prior to making the full-time versus part-time decision include:

  • Complexity of tools
  • Practitioner development
  • Turnover
  • Costs

Complexity of Tools
Many of the healthcare quality improvement tools historically applied were largely driven by facilitation skills. The general line of thinking was that anyone with good interpersonal skills could either teach themselves to facilitate; or with minimal training, they could learn the requisite skills. While modern methods require excellent interpersonal skills and knowledge of facilitation techniques, they go well beyond that.

Lean practitioners require specific training in process mapping and value analysis. Additionally, specific Lean healthcare solutions such as single piece flow, quick changeover, mistake proofing, visual management, and work cells require training and application experience to hone. While Lean applies specific tools, it is still largely reliant on team facilitation. Conversely, Six Sigma is much more reliant on tools. Although team-based, tools are what imbeds the rigor in Six Sigma’s root cause analysis and solution identification.

Highly proficient Six Sigma practitioners have literally dozens of tools in their toolbox. Many of these tools are complex statistical analysis tools that are commonly taught over entire semesters of college courses. With pressure to get the right answers quickly, these practitioners must be able to reach into that toolbox and grab the right tools and apply it correctly. This level of confidence and competence requires repetition.

Constraints Management experts are trained in concepts that are grounded in systems thinking. Constraints Management looks at elements such as materials, information, and money flows. It encompasses techniques useful for operations and logistics (Drum-Buffer-Rope, Critical Chain Project Management, and Buffer Management), performance measurement (Throughput Accounting), and problem solving and planning (Thinking Processes). The innovative thinking involved in these techniques require practice and mentoring to master.

Practitioner Development

While many healthcare organizations realize great success with process improvement deployments, some fail to attain the levels of success that they hoped to. One factor is failing to develop practitioners. The Apprentice-Journeyman-Master developmental model for performance improvement practitioners is widely accepted. In the classroom, the subject matter, pace, and timing of the knowledge transfer is largely controlled by the curriculum. How is that transfer controlled during the subsequent learning—the progress into the journeyman and master levels?

From the initial application in the guilds of Europe, the apprentice-journeyman-master model has lived on in many professions. Electricians, pipefitters and plumbers are obvious examples in that they maintain the same naming conventions. In academia today, the approach is used under different names. A thesis or dissertation needed to get an academic degree is examined by master practitioners—professors—much in the same manner as a journeyman cabinetmaker may have had to have his best work reviewed by a master cabinetmaker in order to be accepted as a master himself.

A healthcare corollary the Apprentice-Journeyman-Master model is the transition from medical student to intern to resident to physician. After the student completes a predetermined amount of didactic learning, the intern begins to practice under the guidance of a mentor; then, based on readiness, the resident begins mentoring less experienced interns; and finally makes the transition to a fully independent practitioner. While not attempting to elevate the complexity or level of knowledge of an advanced performance improvement practitioner with a fully qualified physician, the developmental path is similar.

When related to the decision regarding full- or part-time status for performance improvement practitioners, imagine how long it would take to develop a newly graduated nurse to a fully self-sufficient nurse when they would only apply nursing skills once or twice a week, or even once or twice a month.

It is important to recognize that staff turnover is inevitable. In many industries, it is a common practice that senior practitioners should serve as full time performance improvement practitioners for two to three years. Even if a more permanent model is adopted, turnover is inevitable—whether the move is upward or outward. With the skills and organizational knowledge gained, it is a loss when these valuable resources leave the organization. Career paths should be developed for these practitioners to grow within the organization—transitioning to the operational side of the organization so the investment can continue to reap benefits.

With this ongoing turnover in skilled practitioners, the performance improvement training program must also be ongoing. This drives the development of organic training and mentoring capabilities. Not only must these departing practitioners be replaced, but healthcare organizations must begin developing advanced practitioners.

When viewed as a cost, the use of part-time practitioners makes sense. But is the highly-skilled performance improvement program a cost center, or is it a profit center? To call performance improvement a profit center seems quite a leap, but a properly deployed program should fund itself at a minimum.

So while sustaining itself, the program would show operational and patient safety improvements. At the opposite end of the spectrum, one healthcare system realized a 30-1 return on investment. Returns in the range of 3-1 to 7-1 range are more common. With returns like this, it must be viewed as a profit center. Increasing effectiveness of profit centers requires investment.

A committed and engaged leadership team will see the benefits to the organization that require dedicated performance improvement practitioners. While a cadre of staff trained in the application of Lean tools can—and should–be dispersed throughout an organization to apply those tools as an adjunct to their real job, the decision to create full-time positions for highly trained Lean Six Sigma Black Belts seems to be an easy one.

If you are interested in learning more about healthcare Lean Six Sigma process and performance improvement programs, download the white paper “10 Common Mistakes in Healthcare Performance Improvement.”

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