Thursday, August 02, 2007

Six Sigma and Your Medical Practice

Here is the conundrum.

Mistakes are unavoidable.

We, as physicians, can't make mistakes.

How can this be reconciled? Well, while we can't completely eliminate mistakes, we can seek to minimize them. In industry, businesses have turned to a concept known as Six Sigma to reduce error, eliminate waste, and maximize profits.

What is Six Sigma? Read the following link, and then I'll explain it in English, as I understand it.

The objective of Six Sigma Quality is to reduce process output variation so that on a long term basis, which is the customer's aggregate experience with our process over time, this will result in no more than 3.4 defect Parts Per Million (PPM) opportunities (or 3.4 Defects Per Million Opportunities – DPMO).

So, in other words, Six Sigma is a quality goal that allows for only 3.4 mistakes in every million cycles of a process. Here is an example that may make it easier to comprehend.

Honda makes cars by the millions per year. Auto production is a complex endeavor with many, individual processes. In order for people to like Honda Automobiles and to want to buy more of them, the cars must be reliable, ie built without errors. By using the concepts of Six Sigma, designers can create processes of making cars that keeps defects--such as faulty ignitions--to a minimum, such as 3.4 faults per million cars made. Other examples of Six Sigma quality include airline and rail safety procedures, though not timeliness, and pharmaceutical manufacturing safety control, among others.

The concept of Six Sigma has been applied successfully in many high production industries in many different sectors from manufacturing, to the airline industry, even to health care. In fact, Six Sigma is becoming somewhat of a mantra in health care as we move into the pay-for-performance era--an era in which medical mistakes are not tolerated.

Medicals practices, both large and small, have found it necessary to increase production--throughput, as we say--in order to maintain profits in the face of rising costs and decreasing reimbursements. The average urology practice sees >80 patients per week per provider in the office. Some practices see 40-60 patients per day per physician! In fact, many patients and providers alike have called this type of practice "the assembly line." With numbers like these, it is no wonder why medical mistakes are on the rise. As you can see, with regards to throughput, physician practices are not unlike manufacturing plants with high production rates.

Medical practices, like auto manufacturing, has many processes that take place many times a day in the normal course of business. These processes may include patient intake and exit, document management, data entry, billing, test ordering, patient recall, etc, and any one of these processes is prone to error. Like the auto industry, error in one process can effect the others down the chain, thus producing a lemon. For example, a front desk worker may forget to add a middle initial to a chart, which may result in mis-filed labs, which may result in treatment errors, and on and on. The busier the practice, the more errors. The more patients seen, the more likely some aspect of the process will break down, mistakes will be made, and efficiency and patient care will suffer.

As physicians and owners of medical practices, we must design--and refine--our processes with the goal of Six Sigma. And if you are a young physician about to enter a practice, you may wish to evaluate a prospective medical practice based on how they do business--their processes--and how the doctors and administrator THINK about these processes. You see, in a solo practice, you design and control the processes, but in a larger group, often the processes were put in place by someone else before you arrived. Unfortunately, while the processes may be theirs, it is often YOUR ASS when mistakes are made. Ask your prospective employer and the administrator if Six Sigma is their goal.

I have started to re-think my processes--how I do things in the office--in an effort to increase efficiency, to reduce error, and to simply be better at what I do.

My goal is Six Sigma.