6 Steps to Perfection

Mumbai-based PD Hinduja Hospital has implemented Six Sigma in six key areas. Sonal Shukla studies the system that makes perfect sense for hospitals wanting to improve quality of care and service to patients.

Change is the only constant. An organisation must constantly change according to the needs of people and times. No institute demonstrates this better than Mumbai-based PD Hinduja Hospital.

After receiving ISO 9002 accreditation in 1997, Hinduja Hospital religiously followed the ISO standards and processes for a span of three years. But soon, it felt the need to have a more customer-centric approach to its internal functioning and a new outlook towards quality management principles.

Though the hospital bed occupancy was at its peak, and OPD and health check-up lobby bursting at the seams, the administration were worried by the number of complaints pouring in from dissatisfied patients. Patient discharge, OPD waiting time and health check-ups were taking longer than patients expected.

Some key members out of 170 that participated in successful implementation of Six Sigma at the PD Hinduja Hospital, Mumbai

Aiming for Perfection

"It took OT support team a month to define the problems and in this process, the problems got much wider latitude" - Sanjay Chandiramani Quality Leader and Co-ordinator of the Six Sigma initiative

As an institute which accords the highest importance to customer satisfaction and delight, the hospital realised it was time to implement some internal quality improvement principles.

In order to identify customer needs and priorities and suitably address them, the hospital chose the Six Sigma methodology of quality management. The hospital chose GE, the pioneer in implementing Six Sigma principles, as a guide for the project implementation.

The first task was to list the problem areas. The hospital located as many as 77. "It was not practical to approach all the concern areas at one time. Hence, the areas were whittled to 30 and then finally to six," explains Sanjay Chandiramani, Quality Leader (QL) and Co-ordinator of the Six Sigma initiative. Peri OP Care, OT Supplies Support, ALOS, Discharge Process, Imaging Reports Turn Around Time and OPD satisfaction were the six areas of concern chosen. The six projects finally began on October 5, 2005, when the scope of each project was finalised.

A posse of 120 consultants and 50 management staff were then assigned to shoulder the responsibility of implementing the colossal project. For every problem area, the first task was to prepare a team and define the project charter. (for details, see graph on facing page)

Subsequently, project-specific questionnaires were drafted and distributed to patients and internal customers, and the results were quantified and analysed by the respective team to arrive at the sample size. The sample questionnaires also engendered the next generation of more detailed questionnaires and the process continued.

To aid this project, Hinduja Hospital chose to use specially-designed 'Minitab' software, which automatically gives all the statistical parameters once the data is entered. GE was instrumental in overall guidance and support while implementing the Define, Measure, Analyse, Improve and Control (DMAIC) steps of Six Sigma methodology in all the six areas. "The training was in classrooms, but included their projects as examples and what should be the next steps there," says the spokesperson of GE. It also trained the teams for using the Minitab software.

Perfecting Peri OP Care

The Peri OP Care project dealt with the peri-operative clinical parameters and the peri-operative patient satisfaction index. "In the clinical parameters, some aspects identified were whether adequate information has been imparted to the patient, the consent of the patient taken before a surgery and the site of the surgery marked to ensure the right surgery was conducted. Whereas, in the patient satisfaction index, the experience of the patient in the room, during his transport to the operation theatre, in the operation theatre, waiting period, and information that the patient receives from anaesthetists, nursing staff and the promptness of the delivery of the service were observed," explains Dr Vinod Chandiramani, Project Champion, Peri OP Care.

For instance, noise was high in peri-operative care and affected patient care. The problem was identified by the Six Sigma team, sign boards displaying 'no mobile phones' were displayed across the wards.

The team did not stop at that. After identifying the causes for noise, patients were asked to grade the noise from different factors according to degree. This further helped to narrow down the problem. "Before Six Sigma, we just knew that the ward was very noisy, but didn't know why and how much. However, now we specify numbers and that is impressive," says Sheela Jaiwant, team member for the Peri OP Care project. Other areas like temperature in the wards, staff response time and patient waiting time have also been taken up and efforts are already bearing fruit.

Now, the Peri OP Care team ensures that doctors take informed consent of the patients, anaesthetists and nursing staff meet patient demands, and important information like blood requirement and the kind of surgery is imparted to patients in advance.

Moreover, Six Sigma has created the approach of a co-ordinate study, where patient feedback is measured in a scientific manner, the problems identified, measured and rectified on a continual basis.

Covering OT

The OT Supplies Support project takes care of availability of stockable material and consignment items in CSSD, bio-med-eng and support services. This project was an outcome of complaints from surgeons, and concerned delay of surgery due to consignment items and routine pharmacy and consumables not reaching the OT.

A team of team champions and surgeons from core specialities was created to look into the problem. "It took a month for the group to define the problems and in this process, the problems got much wider latitude," says Chandiramani. Meanwhile, other problem areas like temperature variation in the OT, problem with the biomedical equipment, and functioning of the OT lights were also listed. Soon, representatives from other departments like engineering, CSSD and biomed were also involved.

Thus, the Six Sigma methodology brought temperature under control by adopting a system to monitor it on a periodic basis. The initiative resulted in reduced complaints from the surgeons.

ALOS well, that ends well

The ALOS project dealt with the length of stay of patients in departments of cataract, hernia, angiography and angioplasty. "There were many perceptions about the actual causes of delay, including delay in discharge because of insurance companies and reluctance of free treatment patients to leave the hospital early," says Chandiramani.

The methodology found that the actual reasons of delay were completely different. "For instance, sometimes there were delays because the discharge after the surgery took longer than expected or because some insurance companies dictated that the patients stay for a certain period of time," says Chandiramani.

The reason for patients' unjustifiable stay in the hospital was calculated and systematically for each case, the administrative, medical and insurance-related causes were identified. The project is already successful and ensures speedy patient release daily from the angiography department.

Discharge, Imaging and OPD

Earlier, the discharge process excluded patients in Accidents and Emergency (A&E), Emergency Intensive Care Unit (EICU), paediatric, day care, and Discharge Against Medical Advice (DAMA). The Discharge Process project analysed and rectified time-consuming aspects and distractions in the discharge process. Moreover, delays from the patient's side were ironed out by preparing brochures with the required explanations.

Earlier, imaging reports turnaround time included inpatient and outpatient, but excluded those requiring clinical correlation and actual pickup of reports by OPD patients. After Imaging Reports Turn Around Time project, the imaging reports turnaround time improved by systematically tapping each step starting from the time of exit of the patient from the imaging department and finding out the time-consuming gaps. Regular maintenance of the equipment now gets monitored to avoid further delays. Also, the hospital now gets the imaging reports supply to OPD on time. The frequency of the delivery to the report to the delivery counter has risen to thrice a day from earlier twice a day.

For The OPD Satisfaction project, whose scope excluded free OPD, health check-up, day care, paramedical consultations and procedures, the satisfaction index was defined, root causes identified, prioritised and implemented.

Quantitative Basis for Decision-making

Six Sigma methodologies have enabled the hospital to take decisions purely based on facts and figures and not just on intuition, perception or past experience. "In this way, it has ushered a positive cultural change in the working environment," says Chandiramani.

This changed approach to tackling the problems has percolated down. The work assigned to every member of the team is documented and approved by Business Quality Council (BCQ). This has been instrumental in making the person aware of his responsibilities of making changes and maintaining them meticulously. Now, the team members measure the exact changes in a performance index. The result of the review will be declared soon.

Spurred by the success of Six Sigma in six projects, Hinduja Hospital aims to take it further in all the other 71 concern areas in the future.

While Indian hospitals dread to implement Six Sigma because of its high standards of excellence, the initiative and signs of victory by a bunch of enthusiasts at Hinduja Hospital will inspire others to also strive for excellence and perfection in patient care.

healthcare@expressindia.com