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The Sigma-Dem-Toyo method

April 2, 2009
by Pete Rivera
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I recently visited my brother's plastic products manufacturing plant. Nothing like a nice linear product process to revamp images of Dr. Deming, Toyota and Six Sigma. They all kind of blur together after awhile and your left with the core belief about quality, resources and process deviations; All data driven of course. I see why it is such an easy thing to look at these processes and imagine the application to the service industry. We have process inputs and outputs, defects, deviations, training, and resource requirements. One of the machines I saw produced plastic cold medicine bottles at an alarming rate. An electronic eye checked the quality to mico-millimeter standards and auto-rejected the product if it did not meet the requirement. Take that EPIC!

The focus at this plant was the machines. They generated the work product and the product is always the same for each individual machine, 24/7. The staff is there to support the mechanical beasts that are really doing all the work. So you have to ask yourself; Is that really our quality benchmark?

Healthcare is much more fluid than churning out patients with a paid stamp on their forehead. Yet we keep insisting that we can wrap manufacturing around it. Are we (healthcare) not the best benchmark for ourselves? Find out who is really streamlined and "sell" that method. Maybe we can give it a Japanese name to give it credibility. The "Yakisoba" method. It's a bunch of noodles, not always going the same way, sometimes has meat, or just vegetables...but it tastes really good.
 

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Write it Dale! Would love to hear from folks tired of wearing those green and black belts.

Jim,
Two other companies come to mind that did similar "exhaustive (and expensive) study of the clinical processes on three medical floors in an American hospital[s]." In this case, they articulated that there goal was to enter the HIS vendor space with strong platforms. Both are billion dollar, US-based companies. That was circa 2001. Today, neither are in that market. And, incidentally, neither proposed Pete or Dale (Amazon blog post) implied vision of raising the service level and quality.

Marc,
I agree with your theme. Science, management and disciplined methodology are the most valuable 50 thousand foot view.

I disagree with your comment:
"No one debates that the processes and the data are different in these two endeavors, they obviously are."  Comparisons, for example, between healthcare information management and banking transactions are often compared as though the level of complexity is roughly the same.

People often attempt to build a case with a convenient, readily understandable metaphor that misrepresents or distorts the clinical realities.  In my experience, all-to-often, business modeling and related analysis are not done in healthcare.  The same is true for economic modeling.

In the spirit of your comment, here's one of my favorite Edward Demming quotes.  After a lecture, an attendee came up to Dr Demming and said "those are lovely shoes you're wearing.  how much did they cost?"  To which Demming replied, "I don't know, yet."  That summarizes the disconnect.  It's not whether to quantify, it's how.

Marc,
Yes (re: opening a discussion around the appropriate language for a reasonableness standard in this area would elevate ...)

That's been the hope of many of the bloggers here, and our numbers and pageview volumes are growing.

My attempt, last year, on RomneyCare and my attempt a few weeks back with Diabetes are examples. I have solicited private, anonymous comments which I've posted here as well. These each addressed discussing the quantitative process improvement options.

There are, however, other confounding factors with this approach working beyond critical mass of conversants. Economic interests and capacity for long term thinking being the leading two. Although I'm no slouch, I'm as limited as most.

If you're interested, you could start your own blog, here or elsewhere. See Anthony!


OK, I think we all agree delivering health care is not the same as making widgets. But to say we should Deep Six — Six Sigma (or LEAN) is going too far!!

There are many, many processes in a hospital that are repetitive, predictable and can easily benefit from applying these tools. Just start with the registration process. Why can a hotel or airline get you in /on board without any human intervention and never have to ask the same questions twice or three times.

I also think there is a great deal of benefit in applying them to procedural medicine, but maybe not so much to cognitive medicine. For example, there can be some variability in removing an appendix, but far more routine and predictability. Kind'a like Joe's commercial printer. On the other hand when a patient presents with a host of symptoms and we go thru the infamous 'rule-out' process there is potentially a ton of variability, - although completing the needed diagnostic workups are very predictable.

IMHO, we will never get the practice of medicine down to a simple science. Maybe that's why they call it the PRACTICE of medicine? Someday with enough practice we just might get it right! But that's no reason to toss out Six Sigma & LEAN.

Nice graph Joe! It really makes the case that variability is inherent in our process and therefor does not fit into a cookie cutter approach. I hope all the EHR folks see this and factor this in when trying to fit docs into "their" workflows.

Exactly, we tend to get caught up in the comparisons and neglect the true nature of our business. Not to mention the diversity of healthcare itself (rural, community-based, academic, private..the list goes on).

Thanks for the comment Joe -

You are right, I made a misleading generalization in order to strengthen my point. This is the same oratorical sin/shortcut committed by those knowledgeable commentators who seriously compare clinical care processes with banking transactions. Mea culpa.

For the moment let's exclude those knowledgeable commentators who disingenuously make the comparison because they know their target audience won't be able to see the differences. These folks are manipulators.

Let's also exclude commentators who make the comparison out of their ignorance of sigma-dem-toyo, clinical and/or financial processes. These folks are simply misguided.

A more accurate statement on my part would probably be akin to legal "reasonableness" standards and would run something along the lines of: no reasonable practitioner of the arts involved would debate that both the processes and the data are qualitatively and quantitatively different in these two endeavors.

I am moderately interested in opening a discussion around the appropriate language for a reasonableness standard in this area. Do you believe that such a standard would elevate the clarity and quality in discussions of quantitative process improvement in healthcare?

Pete,
Thank you. Here's a diagram I found in a textbook years ago that graphically makes your point. 

Healthcare is most like a 'Commercial printer.'  The processes are characterized by Jumbled flow, relatively low volumes, low standardization (appropriate) to lots of one of a kind work. Attempting to cast it as Auto assembly is miscategorization.  (It's also experienced as demeaning and condescending to it's practitioners.)

Caring for patients is not building widgets, yet caring for patients, like building widgets is amenable to the scientific method.

The scientific method can be abbreviated as observe-hypothesize-test-retest. Repeated cycles can lead to theories, theories generate models and models are the templates on which care is provided or on which a machine is built and its raw materials designed.

In both cases new hypotheses can lead to new tests can lead to new theories can lead to new models can lead to improvements in patient care or in the manufacturing of cold medicine bottles. Obvious examples are the differences in say the treatment of peptic ulcers before and after Barry Marshall demonstrated the role of H. pylori by drinking a petri dish full of the organism and the differences in the manufacture of glass cold-medicine bottles before and after the transistion to plastic cold-medicine bottles.

Testing and retesting is a quantitative endeavor that requires measurement and statistical analysis. It is also the heart of the scientific method and it is its central distinguishing feature.

So, let's not throw the baby out with the bathwater. There are obvious differences between a widget factory and a hospital or clinic, and Sigma-Dem-Toyo should not be blindly employed to tackle all processes in an slavishly identical manner. In the same way that a claw hammer can be used to pound a nail, separate two boards or engage a dovetail joint, so can Sigma-Dem-Toyo be tailored to the process at hand.

Apologies for the mixed metaphor in the previous paragraph, but I hope this comment has been helpful. In summary, I see this notion of process improvement is different in healthcare and manufacturing as a false dichotomy. No one debates that the processes and the data are different in these two endeavors, they obviously are. But any process and all data associated with that process are amenable to the scientific method.

Frank, I get to visit organizations and review processes and develop gap analysis based on current versus "Best Practice." I agree with you in that the industry that we are in lacks procedures and process simplifications that are inherent in other industry (banks, hospitality). But were we deviate is the diversity, over-regulation, legal requirements and common process spikes (anomalies) that makes it difficult to apply Healthcare "Best Practices" to most organizations..let alone purely analytical analysis. We (healthcare) do not fit in a nice group with consistent widget production.

Yahoo, Pete! I've been through every process improvement methodology known to mankind in the Air Force, at TRW, at Intel and Motorola, now in healthcare. Six Sigma is the soup of the day, but it's a mismatch. You've prompted me to write a new blog entry Deep Six Your Six Sigma!

Frank,
I agree with you completely. There are a ton of processes, from starting a life-saving medication to getting a room clean, than can and should be routine and predictable (including dealing with their common failure modes.)

A few years back, chaos theory was at its peak of wild enthusiasm. One of the important lessons was, for many processes, predicting the future state was impossible. However, predicting whether the process was stable and the boundaries within which it was stable was the important thing. You can and should use the tools of Six Sigma, including control charts, to monitor those processes.

Great post, Pete. I was fascinated to learn about the Toyota production system (and some of its counterparts, which professed to be different but were built around the same basic idea). While I can certainly see the appeal of implementing a system to cut out the fat, particularly in these economic times, I love the point you bring up that we're not talking about mass-producing cars - we're talking about caring for patients.

Caring for patients is not building widgets, yet caring for patients, like building widgets is amenable to the scientific method.

The scientific method can be abbreviated as observe-hypothesize-test-retest. Repeated cycles can lead to theories, theories generate models and models are the templates on which care is provided or on which a machine is built and its raw materials designed.

In both cases new hypotheses can lead to new tests can lead to new theories can lead to new models can lead to improvements in patient care or in the manufacturing of cold medicine bottles. Obvious examples are the differences in say the treatment of peptic ulcers before and after Barry Marshall demonstrated the role of H. pylori by drinking a petri dish full of the organism and the differences in the manufacture of glass cold-medicine bottles before and after the transistion to plastic cold-medicine bottles.

Testing and retesting is a quantitative endeavor that requires measurement and statistical analysis. It is also the heart of the scientific method and it is its central distinguishing feature.

So, let's not throw the baby out with the bathwater. There are obvious differences between a widget factory and a hospital or clinic, and Sigma-Dem-Toyo should not be blindly employed to tackle all processes in an slavishly identical manner. In the same way that a claw hammer can be used to pound a nail, separate two boards or engage a dovetail joint, so can Sigma-Dem-Toyo be tailored to the process at hand.

Apologies for the mixed metaphor in the previous paragraph, but I hope this comment has been helpful. In summary, I see this notion of process improvement is different in healthcare and manufacturing as a false dichotomy. No one debates that the processes and the data are different in these two endeavors, they obviously are. But any process and all data associated with that process are amenable to the scientific method.

Caring for patients is not building widgets, yet caring for patients, like building widgets is amenable to the scientific method.

The scientific method can be abbreviated as observe-hypothesize-test-retest. Repeated cycles can lead to theories, theories generate models and models are the templates on which care is provided or on which a machine is built and its raw materials designed.

In both cases new hypotheses can lead to new tests can lead to new theories can lead to new models can lead to improvements in patient care or in the manufacturing of cold medicine bottles. Obvious examples are the differences in say the treatment of peptic ulcers before and after Barry Marshall demonstrated the role of H. pylori by drinking a petri dish full of the organism and the differences in the manufacture of glass cold-medicine bottles before and after the transistion to plastic cold-medicine bottles.

Testing and retesting is a quantitative endeavor that requires measurement and statistical analysis. It is also the heart of the scientific method and it is its central distinguishing feature.

So, let's not throw the baby out with the bathwater. There are obvious differences between a widget factory and a hospital or clinic, and Sigma-Dem-Toyo should not be blindly employed to tackle all processes in an slavishly identical manner. In the same way that a claw hammer can be used to pound a nail, separate two boards or engage a dovetail joint, so can Sigma-Dem-Toyo be tailored to the process at hand.

Apologies for the mixed metaphor in the previous paragraph, but I hope this comment has been helpful. In summary, I see this notion of process improvement is different in healthcare and manufacturing as a false dichotomy. No one debates that the processes and the data are different in these two endeavors, they obviously are. But any process and all data associated with that process are amenable to the scientific method.

I just reviewed a case for an international process improvement company trying to break into the healthcare market. They did an exhaustive (and expensive) study of the clinical processes on three medical floors in an American hospital. They were perplexed by the near total lack of implementation and impact of their "suggestions" after a few months. The message: "If it were easy we would have done it already."

Pete Rivera

Director Informatics, Hayes Management Consulting

Pete Rivera

@Gator_Pete

www.Hayesmanagement.com

 

 

 

 

 

 

 

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