Wednesday, 14 December 2011

Biggest Lean Deployment in the World

The American Army has the largest lean six sigma deployed in the world.

The American army budget is currently more than $240billion
The US Army has deployed Lean since 2006 and saved $19.1 billion dollars
so far. In 2011 alone they are conducting 2111 lean improvement projects
to save $3.6 billion.
They have 5700 green belts, 2400 Black Belts and 175 Master Black Belts
and 48 Lean Deployment Directors. Their return on these investments have
been very good.

Most of the projects have been about logistics but their health care is
also heavily into lean. They have seen great successes.

Here is an interesting anecdote from one of their early projects -
obviously dated but the learning value is undiminished.

According to the principles of lean six sigma, US Army Medical Command
looked into high volume areas, 'waste' and 'customer satisfaction'
problems and found that they had:

The largest army call centre with more than 10000 calls per week
Low customer satisfaction at 68%
Average wait time of 3.14 minutes (wait is one of the classic wastes in
Call abandon rate of 26% - with a peak time call abandon rate of 49%

Obviously they found this very unsatisfactory and ran a lean project to
improve this. And they improved:

Average wait time reduced to 33 seconds (a six-fold improvement)
Call abandon rate reduced to 3% with peak time call abandon rate down to 22%
Call volume reduced 20% due to less call backs
and so on

These results were far better than the aims they set themselves for the

Apparently the customer satisfaction got worse!!

While people were getting their calls attended in record time they could
not get appointments to see doctors in clinics because the clinics had
capacity and scheduling problems - so the issue was, what is the point
in answering the phone quickly if they could not address the real need
which is patients to see doctors quickly.

Do not despair!

They have since addressed that issue and that has had an even bigger
effect on their call centre

The average waiting time has fallen to 3 seconds (yes, you read it right
THREE seconds - from their starting point of 3 minutes and 14 seconds)!!

There are two messages, a) system wide thinking is difficult but very
important b) it is even more important to solve the real issue (rather
than what is immediately apparent).


Note: The above is written from my recollection and notes of a brilliant presentation made at the WCBF Lean Six Sigma in healthcare conference 2011; with thanks to the presenters from the US Army Health Command and their collaborators.

Friday, 9 December 2011

Single Visit Surgical Service

When we look at providing healthcare services we should look at it from a patient's perspective. For instance, ''how often would the patient have to travel to the hospital to obtain healthcare services?'' is not the top question in any providers mind when they design the service.

This results in the patients traveling often to secondary care services even for obviously clear problems such as hernias, varicose veins etc.

At Goole Hospital we provide a single visit general surgery service for patients who need day case and short stay surgical procedures. This may mean procedures likes superficial lumps and bumps, toe-nails, etc. This also means patients who have groin hernias including recurrent groin hernias and gall stones (needing laparoscopic cholecystectomy).  Obviously there has to be a clear cut diagnosis based on obvious findings followed by some appropriate investigations by the general practitioners. These patients visit Goole Hospital only once to obtain their surgical care. The patients are telephone pre-assessed. They come to the hospital at about 8 am and are seen by nurses, anaesthetists, surgeons and residual simple investigations are performed instantly; they are operated during the day and discharged when they meet clinical criteria often within the day. They are not offered specific follow up out patient appointments but can ring to make one if they felt they needed it.

We do inguinal hernia repairs, laparoscopic cholecystectomies and many other procedures as a part of this service. The service has been running for a good few years.

My personal calculations are that this saves money overall, especially saves on travel costs for patients and their relatives. My feeling is many of the services provided by healthcare are currently very hospital focussed. When the processes becomes patient focussed there is a good chance that quality could improve while saving on costs at the same time. It is up to us to manage our services and processes maturely - our poor design should not trouble the patients.

Follow me on twitter @HemadriTweets

Warning & Disclaimer:
We do not claim superior clinical results. We only describe our process/pathway. Not all patients with any of the conditions stated above or with other similar conditions are suitable for this service. Your GP is best placed to advice the kind of pathway that could be suitable to you. This blog/website does not give clinical/medical advice. The views expressed are my personal views and not those of my hospital or the NHS.


Thursday, 1 December 2011

Laser surgery for piles

Many of you will be aware that piles is a very common problem presenting usually as bleeding and/or swelling from the anus. If the piles involves an external swelling at the anus along with the bleeding then a surgical operation may be indicated.
Currently the standard method of doing a piles operation involves a general anaesthetic, cutting out the piles (called open haemorrhoidectomy or Milligan-Morgan technique) and possibly an overnight hospital stay though more centres are doing piles operations as day cases.

We (Peter Moore, Consultant Surgeon, now retired and I) have been performing a technique called Laser Seal Haemorrhoidectomy for a few years where we use a local anaesthetic with mild sedation and use a laser to seal the cut edges of the piles. Patients are able to go home about 2 hours after the operation (they may be able to go home earlier but sedation guidelines kick in I suppose), we believe that this procedure gives better pain relief in the early days  

We learnt this procedure a few years ago from Peter Thomas from Arizona; of course we don't do it exactly like him and he has been doing it for 25 years.  A public thanks to Peter.

I think to change an operation that involves a general anaesthetic and often one or two nights of stay in the hospital to a local anaesthetic (with mild sedation) with a two hour stay is our local technical example of Success in Healthcare. Surely not an earth shattering example, only a small one but hopefully relevant for some. The point is to try and pursue every activity that improves quality and decreases cost at the same time.

Follow me on twitter @HemadriTweets

Warning & Disclaimer
1) There are many causes of bleeding from the anus and many causes of swelling in the anus, some of those may be more serious conditions than piles - please consult your doctor whose advise will be the only thing relevant to you personally. This blog does not give you medical advise.
2) We do not claim scientifically superior results. We describe only our process and some of our beliefs.We use the laser seal haemorrhoidectomy as a clinical process improvement example not as scientific proof of any treatment.

Amended on 30 August 2014