Improving the workflow of the One Stop Shop
for palliative radiation therapy
using Lean Six Sigma
Martijn Kamphuis (m.kamphuis@amc.nl)
Student Number: 10973206
Master Thesis MBA Health Care
Supervisors: T.S.Akkerhuis (ABS-UvA), I.G.F.M.Wanders (AMC)
Date of submission: 30-01-2017
Abstract
There is a growing body of evidence for the effectiveness of Lean Six Sigma (LSS) as improvement methodology in Healthcare. No literature is however available on its
effectiveness in the field of radiation therapy. On top of that, is the fitness of LSS in settings in which multiple goals must be achieved questioned in literature. The academic
environment, in which radiation therapy often take place, has competing goals like education and research.
Palliative radiation therapy, e.g. for the treatment of painful bone metastases, is considered a successful and efficient treatment method. At the AMC in Amsterdam, the treatment is during working hours organized in a so called “one stop shop” (OSS). This means that patients are seen by the radiation oncologist, treatment is consecutively prepared and patients are treated on the same day. The throughput time (TPT) of this procedure is about 5 hours, but in about 15% of the cases more than 6 hours. The TPT was considered undesirable by the medical staff of the department, especially since patients are often in a poor
condition or suffering.
The aim of this study to was reduce the current workflow of the One Stop Shop at the AMC in Amsterdam from 5 hours to less than 2:30 hours by using LSS. First, a multidisciplinary team was formed. Second, the problem was transferred into a quantifiable characteristics. Third, a baseline measurement was performed in 30 patients using a travel sheet approach. Fourth, the process was analyzed using a value stream map.
Different techniques were used to determine factors influencing the length of the OSS. A re-design of the process was created based on gained insights and in collaboration with
important stakeholders involved in the OSS process. The redesigned process was tested in a pilot study.
A significant decrease in TPT of 1:36 hours on average was achieved In the pilot study. The foreseen TPT reduction of 2:30 hours could not be reached. LSS was proven to be successful in optimizing the workflow of the processes in the field of radiation therapy. The academic environment however, limits the possibility to further reduce the impact of important influencing factors.
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Content
Abstract ... 2
I Introduction ... 5
Improving the workflow of the One Stop Shop for palliative radiation therapy ... 5
Process improvement, a historical overview: ... 6
The aim of this thesis ... 10
II Methods ... 10
Introduction ... 11
General description of the Lean Six Sigma methodology ... 11
III Results: Lean Six Sigma at the One Stop Shop ... 14
The Define phase of the One Stop Shop project ... 14
IV Measure ... 18
Introduction ... 18
Defining the CTQ’s ... 18
Operational definitions of the CTQs ... 19
Measurement plan ... 19
Designing a valid measurement procedure ... 19
Data collection ... 21
V Analyze ... 23
Introduction ... 23
Diagnose the current process; the value stream map ... 23
Recalculating the business case ... 26
Benchmarking ... 26
Identifying potential influence factors ... 26
VI Improve ... 30
Introduction ... 30
Identifying the highly influential and changeable factors ... 31
Redesigning the workflow of the OSS ... 32
The pilot study ... 34
VII Control ... 36
VIII Discussion ... 38
Literature ... 41
Appendix 1: The original project charter... 51
Appendix 2: The travel sheet ... 52
Appendix 3: The process matrix ... 54
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I Introduction
Improving the workflow of the One Stop Shop for palliative radiation therapy
Radiation therapy is a cancer treatment using ionizing radiation to kill tumor cells. Radiation therapy is often delivered using a linear accelerator. This is called external beam radiation therapy. Treatment is delivered in 1 to up to 40 treatment sessions. Radiation therapy is one of the most important treatment modalities in the field of oncology. It is estimated that in 52% of all cancer cases external beam radiation therapy is indicated1.
When it comes to the palliative treatment of e.g. bone metastases, radiation therapy is considered a successful and efficient treatment method2. In a palliative setting, pain relief is the main goal of the treatment. Much research has been focused on the optimal amount of treatment sessions to deliver the treatment. At this moment, a single treatment session of 8 Gy is considered most optimal3.
Palliative radiotherapy is often performed with a non-complex one- or two-field treatment technique. Nowadays, this procedure is based on CT-images and is often time consuming. At the AMC in Amsterdam, the procedure is organized during working hours in a so called “one stop shop” (OSS). This means that patients are seen by the radiation oncologist, treatment is consecutively prepared and patients are treated on the same day. The throughput time (TPT) of the whole procedure is about 5 hours, but in about 15% of the cases more than 6 hours. The TPT was considered undesirable by the medical staff of the department, especially since patients are often in a poor condition or suffering.
TPT has two constituents, being processing time and waiting time. Processing times (PTs) are the time periods in which hospital personnel are physically helping the patient. Waiting times (WTs) are the times that a patient is waiting for processing (or more specifically: treatment). Another form of WT occurs between the different processing steps of the procedure. There is a need to reduce both parts of the TPT. Reducing the PTs can save personnel costs, and reducing the WTs has a large effect on the TPT, since WTs are usually by far the largest component of the TPT. By reducing the TPT, patient satisfaction is expected to go up.
To be able to improve the TPT, an effective improvement technique is needed. Different techniques are described in literature and will be explored in the next paragraphs.
Process improvement, a historical overview:
Below, a brief historical development of process improvement will be presented. The following phases of process improvement will be discussed in this section: scientific
management (SM), total quality management (TQM), (Business) Process reengineering (BPR) and Lean Six Sigma (LSS).
Scientific management
One of the first described attempts to improve processes is scientific management, a method developed by Frederick Winslow Taylor and published in 19114. His method consisted of four principles5:
1. Replace guesswork methods with a scientific study of the tasks. Decision should be made based on data rather than on gut feelings.
2. Select, train, and develop each worker rather than leaving them to train themselves.
3. Ensure that the scientifically developed methods are being followed.
4. Make sure the managers apply scientific management principles to planning the work and the workers actually perform the tasks.
This method formed the basis for more recent improvement techniques. There are different reasons why scientific management became out of fashion6:
Conflicts occurred with labor organizations.
People felt like being treated as machines:
o No or little room was available to work in a personal way.
o The technique offered no space for soft side of work, in the end creating a big source of resistance.
o Due to the fact that bottom-up improvements are unlikely to happen, a potential source of improvement is left unused.
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Due to the increasing resistance from employees, scientific management became outdated5. Decision-making based on data however, is still a principle that was used in many successive improvement techniques.
Total Quality Management
In the Total Quality Management (TQM) philosophy, continuous improvement of quality is an effort that is supposed to be made throughout the whole organization. The origin of the term is uncertain7. The technique dates from the 1980s and was developed by W.E.Deming8 as a reaction to the economic crisis at that time9. TQM movement gave insight in the importance of focusing on quality.
The vision of TQM is that optimal improvement is achieved if a whole organization is committed to quality10. The assumption behind TQM is that there is a direct relation between quality and customer satisfaction18. Improving quality will lead to an increase in customer satisfaction, together with reduction in production costs.
Another principle of TQM is the supposition that there is always an opportunity for
improvement in every process on every occasion11 . The Plan-do-check-act (PDCA) is often considered to be part of TQM, but in formally it was designed by Walter A. Shewart12 much earlier.
(Business) Process Reengineering (BPR)
(Business) Process Reengineering (BPR) is a method that was proposed by Michael Hammer in 199013. In his book “Reengineering work: don’t automate, obliterate” Hammer states that it is more important to remove non-value adding activities rather than to automate them. In Hammer’s opinion, dramatic improvements can only be achieved with reengineering rather than with continuous improvement actions based on e.g. a PDCA cycle. (B)PR showed that re-design, using a process flowchart, can be a powerful tool improve processes.
Like with scientific management, little attention was given to the human dimension of the reengineering process, which was ultimately recognized by its founder11. BPR became soon associated with downsizing and resignations14. Redesign, in combination with resignations, made organization become more vulnerable since the knowledge and experience base is too small to cope with unexpected changes15.
Lean Six Sigma
Lean Six Sigma is an improvement technique that combines Lean management, originally called the “Toyota production system” as it was developed at Toyota, and Six Sigma, which was developed by Motorola and gained further attention after impressive results at General Electric16. Lean Six Sigma is an approach for breakthrough improvements.
Lean can be defined as follows: “Lean manufacturing is a comprehensive philosophy for
structuring, operating, controlling, managing and continuously improving industrial production systems.”17
Underneath the philosophy, Lean has different principles like “Focus on flow” and “Making problems visible”. Besides that, Lean is associated with a lot of different best practices like “Value Stream Mapping”, “Poka-Yoke” and “the Daily Huddle”18.
Six Sigma is based on different principles18:
“Improvement based on understanding of the causes”: do not try to improve based on gut feelings.
“Precise and operational problem definition”: first define and quantify a problem
before trying to find a solution.
“Quantification of problems”: Translations of the problem into a measurable quantity.
“Data-based diagnosis before solution attempts”: quantify the current performance
of a problem.
“Data-based testing of ideas and improvements”: test improvements in e.g. a pilot
study before putting definitive solutions into practice.
Six Sigma offers a roadmap to approach problems in a very systematic manner. This roadmap is called DMAIC and consist of 5 phases18: Define, Measure, Analyze, Improve and Control. The five previously mentioned principles are embedded in the different phases of the roadmap. In the measurement phase for instance, the problem is translated into a measurable quantity affecting the outcome or quality of a process. In the improve phase, ideas for improvement are being tested before being implemented.
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Lean Six Sigma can be perceived as a next step in the development of the scientific approach to improve processes18. Lean Six Sigma builds on the experience and insights coming from previously described techniques. The combination of Lean and Six Sigma works well. Six Sigma offers a managerial framework and a problem-solving roadmap that relies on statistical techniques. Lean adds valuable standard solutions and best practices to this framework19.
Lean Six Sigma in the academic context
Previously described strategies were published in handbooks and written by experts in the field. According to the Oxford CEBM Levels of Evidence, this is the lowest form of scientific evidence (level 5) 20.
For LSS however, there is a growing evidence (level 3 to 4) coming from peer reviewed papers. At least 5 recent systematic reviews are available on the use of LSS in Healthcare. All systematic reviews conclude that LSS can help in improving healthcare21-25. Moreover, these authors find that there is still a need for higher quality research on LSS, e.g. in the form of randomized controlled trails21-25.
The absence of definite scientific evidence justifies local case studies to find proof for the effectiveness of LSS in a specific setting. When it comes to the field of radiation therapy, no publications are available on the effectiveness of LSS. This further enhances the need to find scientific evidence to be able to apply this improvement technique into practice.
A final need for more research can be found in the academic context in which this project takes place. The academic hospital delivers, next to patient care, education for paramedics, medical students and doctors. On top of that, the hospital is an environment in which a lot of research take place. These three major activities can lead to competing interests.
Optimizing a process in patient care might harm the educational or research function of the hospital and should therefore be taken into consideration during a LSS improvement project. Very little research has been performed on optimizing multiple goals using LSS26.
The aim of this thesis
Is it possible to reduce the current workflow of the One Stop Shop for palliative radiation therapy at the Academic Medical Center in Amsterdam from 5 hours to less than 2:30 hours by using Lean Six Sigma?
The next chapter summarizes the methods used in this thesis. The Lean Six Sigma roadmap for process improvement will be presented. This roadmap proposes that process
improvement be executed in five phases: these are all presented in the Results chapter (II-VII). In the last chapter (VIII), the research question will be answered and a discussion will follow.
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II Methods
I
ntroduction
To improve the workflow of the “One Stop Shop” (OSS), Lean Six Sigma (LSS) was chosen as the improvement method to use. In this chapter, the LSS methodology will be detailed and applied to the OSS project.
General description of the Lean Six Sigma methodology
LSS has a well-structured method consisting of 5 phases; the Define phase, the
Measurement phase, the Analyze phase, the Improve phase and the Control Phase. In this
chapter the general DMAIC procedure will be explained as described in the book “Lean Six Sigma for Services and Healthcare”18.
The Define phase of a LSS project is a three-step procedure. First, a process with sufficient potential for improvement (often also, not completely accurately, called a “problem”) is identified. If no specific problem is known that needs to be addressed, the LSS methodology provides tools that help identify problems. The second step in the Define phase is to create a project charter or project proposal. In this document, the process is described e.g. using a flowchart, project benefits are calculated, project details are described and a project team is proposed. In Lean Six Sigma organizations, the proposals are submitted to the program management. Based on the organization’s strategy and the potential benefits of the project, the management allows a selection of project proposals to continue18.
In the Measurement phase, the problem is translated into measurable variables that affect the quality or outcome of a process. These variables are a called Critical To Quality
characteristics, or CTQ in short. Although this abbreviation refers to the concept of quality, other indicators that are not strictly related to quality, are allowed as well. Every CTQ should be accompanied by detailed definitions. Finally, a project leader creates a measurement plan in which the measurements are planned. This includes judiciously determining a sampling period and sample size. The validity of the measurement plan is tested both before (by brainstorm sessions and test measurements) and after (by checking face validity and
investigating outliers or other unexpected phenomena in the data) the start of actual measurements. The scientific component of the LSS method is clearly seen in this step, as not only data is collected per se, but the reliability of the data thus obtained is subject to scrutiny18.
Next is the Analyze phase. First, a diagnosis is performed, usually by graphical methods (histogram, boxplot, Pareto chart etc.), descriptive statistics (mean, standard deviation) and by comparing the performance to Service Level Agreements (SLA). When a project is aiming at workflow enhancement, a value stream map is often used to identify wastes and the bottleneck in the process. Based on the acquired data, the project’s benefits (as described in the project charter) are recalculated. This is the final go/no-go moment of the project: if the problem turns out to be much smaller than expected, the project is aborted18.
In the second part of the Analyze phase, factors influencing the current performance of the process, or in particular: the CTQs, are identified. There is a large variety of methods
proposed to identify as much factors as possible, like the Failure Mode and Effect Analysis (FMEA), brainstorming session or a Gemba walk (workfloor inspection or walkthrough). Trying to find as much factors as possible, and to consider as many directions as possible, ensures the scientific quality of the method: it eliminates “gut feelings”. Eventually, an extensive list of potential influencing factors is composed. The influencing factors are collected in a spreadsheet called the process matrix18.
The first step of the Improve phase is to identify, within the extensive list of potential
influence factors, the most important ones (the vital few), being the factors that have a large impact on the CTQs and are easily changeable. When the vital few influencing factors are identified, improvement actions can now be designed. However, as LSS is a scientific method, the effect of the vital few influence factors should be proven. Statistical analysis is often used. Different strategies, like process reengineering, are available to improve the performance of the process18.
The final stage of a DMAIC project is the Control phase. In the control phase, actions are carried out to ensure that the results of improvements are retained. Like in other phases, different tools are available to successfully achieve this goal, such as statistical process
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control27. With either calculation of the realized benefits, or with the creation of a detailed implementation schedule, the project can be closed. The project leader then is discharged and hands over responsibility to the process owner18.
III Results: Lean Six Sigma at the One Stop Shop
The Define phase of the One Stop Shop project
The first step in the Define phase is to identify the project. In this thesis, it is the One Stop Shop for palliative radiation therapy treatment at the Academical Medical Center (AMC) in Amsterdam. The process was originally prepared using a machine called the conventional simulator. The whole preparation process took less than one hour. The current procedure is based on an acquisition of a CT-scan and is far more time consuming.
Previous attempts have been made (unsuccessfully) to decrease the length of the procedure. Faster procedure are available but can often not be used due to technical limitations30.
At the same time in the department, other Lean projects are running to improve the workflow of comparable processes, trying to solve similar problems. No quick fixes are available at the start of the project.
The second step in the Define phase is to create a project charter. The complete project charter can be found in the appendix 1. We describe below some important parts of this document:
a flowchart of the process,
the project benefits that can be realized,
the organization of the project.
The flowchart of the process
The whole process of the One Stop Shop, from announcement of the patient to completion of the treatment, is described in a flowchart. This flowchart was created by the chair of the working group that was formed to perform the OSS project. Working groups members were ask to feedback on a draft. The final flowchart can be found in Figure 1, that has been refined using the remarks of working group members.
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Figure 1: Process description of the One Stop Shop.
The aim of this project is to optimize the workflow to be able to decrease the length of stay of a patient in the department. For that reason, only the part of the process in which the patient is present on the department will be considered, starting the moment the Radiation Oncologist (RO) sees the patient. The phase in which the appointment is made (“balie 1”) will not be taken into account in this analysis.
Project benefits
This project aims to decrease the time spent on preparing and performing a straightforward radiation therapy treatment. The first, and according to the hospital’s strategy, goal of the project is to improve the comfort and quality as perceived by the patient by reducing the throughput time (TPT). In this thesis it is assumed that is a direct relation between TPT and patient satisfaction.
A TPT reduction for patients will be reached by reducing waiting times for the patient, but also by reducing processing times of the medical personnel. The latter will directly lead to the second benefit of the project: a reduction in labor costs. The anticipated reduction of the throughput time is 2,5 hours. Daily, 1 or 2 patients can be treated with the OSS on the
department. 8 OSS time slots are available on a weekly basis. For calculating the financial benefits, it is assumed that a reduction in both waiting time and processing time lead to a reduction in labor costs. This is reasonable since, as long as a patient is at the department, at least one medical professional is present there as well. The financial benefits can be
estimated as follows:
In case the project succeeds, 2,5 hours reduction in TPT is anticipated.
2,5 hours work reduction for 2 radiation therapists (RTT’s) is applicable for 8 patients/week
2,5 hours*8 patients/week = 20 hours RTT/week (0,5 FTE) reduction
Assuming a 0,5 FTE reduction, 0,5 FTE*70,000 euro (estimated average salary of an RTT including costs) = 35,000 euro saving can be achieved.
Estimated is also a reduction of working time of the MD: 1 hour/patient for 8 patients per week (0,2 FTE).
Assuming a 0,2 FTE reduction, 0,2 FTE*100,000 euro (estimated average salary of a MD including costs) =20,000 euro saving can be achieved.
Total cost reduction is approximately 55,000 euro/year in case all OSS treatment slots are used.
There are some additional benefits to the project. An optimized workflow can also be
exploited to market the department on scientific as well as on patient related or commercial platforms.
Furthermore, process improvements can easily be transferred to all other treatments that take place on the radiotherapy department since they follow the exact same routing.
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The organization of the project
The organization of the project consisted of a working group and a supervision board*:
Supervision is performed by MBA faculty member, Thomas Akkerhuis PhD, together with the process owner, drs. Iris Wanders, manager of the radiation therapy
department.
The workgroup consists of members representing all disciplines involved in the execution of the process:
o Chair of the working group:
Martijn Kamphuis MSc. radiation therapist, clinical epidemiologist, MBA student.
o Working group members:
Karin van der Klis MD, Radiation oncologist.
Kelly Kruithof BSc. Radiation therapist, treatment preparation location Almere.
Judith van Gelder BSc., Radiation therapists, treatment preparation location Amsterdam.
Yvonne da Lima BSc., Physical therapist, coordinator logistics.
The project was approved since the DMAIC methodology was deemed suitable for reaching the benefits as estimated in the previous section. As patient satisfaction is a major concern of the hospital, the financial benefits of this project are optional and may be reinvested in further improving the patient satisfaction.
*
IV Measure
Introduction
In this chapter, all preparations for the acquisition of valid data will be described. Thereafter, the efforts for acquiring data will be presented.
Defining the CTQ’s
In the Measurement phase, the problem is first translated into a measurable characteristics. These are called Critical To Quality (or CTQ in short). There should be a strong relation between the CTQs and the goals of the project. In this project four different CTQ’s can be distinguished:
1. Idle Time,
2. Treatment time (or processing time) without the patient, 3. Treatment time (or processing time) with the patient, 4. Waiting time of the patient.
CTQ 1 to 3 are the total time spent by professionals. By reducing the length of CTQ 1-3, the labor costs of the process will decrease consequently. This is the second goal of the project. On a strategic level, this decreases the operational costs of the department.
CTQ 3 and 4 are units effecting the quality of the process as perceived by the patient. Reducing the TPT on the department is assumed to directly increase the patient satisfaction which is the main goal of this project.
The theoretical CTQs of the project and their relation to the goals and the strategic focus of the department are visualized in figure 2 below.
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Figure 2: the CTQ’s of the OSS project
Operational definitions of the CTQs
Clear operational definitions were constructed. The measurement unit is chosen as “minutes”. The unit of study is a patient, meaning that one observation of the CTQ is collected per patient. The CTQs are calculated based on start- and endpoints of process steps.
Measurement plan
The construction of the measurement plan consists of designing a valid measurement procedure, and scheduling the actual collection of data. It was created in collaboration with the working group. A first draft was made by the chair of the committee.
All working members gave input, mainly on the part in which they contribute in the process execution:
Kelly Kruithof and Judith van Gelder commented on all parts of the process,
Karin van der Klis made some revisions on the steps in which the MD is involved,
Yvonne da Lima had general remarks on the form.
Designing a valid measurement procedure
For this project, the “travel sheet approach” was chosen. A travel sheet is a form that is assigned to each patient. Every time someone performs a process step on the patient, he or she writes down, on this travel sheet, at what time processing started, and at what time
processing ended. With this information, by subtracting starting times from ending times, processing times can be calculated. And by subtracting end times of step Y from starting times of step Y+1, waiting and idle times can be calculated. The name “travel sheet” comes from visualizing a patient “traveling” through the process, accompanied by this sheet25. In the project the travel sheet was handed from professional to professional.
The choice for the travel sheet methods has important implications for the analyses of the process. Not all elements in the CTQ flowdown, as presented in figure 2, can be quantified using this technique. On the travel sheet, processing times (PT) are registered per step and can be summed to a total processing time. The times between the steps, which can be calculated by subtraction, can be regarded as waiting time (WT). The throughput time (TPT) is the sum of all waiting and processing times. From the patient perspective, the TPT is most important**. From the labor costs perspective, the sum of all processing times is most meaningful. With the data from the travel sheet, the major goals of the project can be quantified. For that reason, this simplification was regard acceptable.
As patients in this process see a lot of different hospital employees, meaning that the travel sheet is to be filled in by many different people, the validity of the travel sheet is put to the test first. Two test measurements were performed, on two patients treated in Amsterdam. Professionals involved in the test were asked to give feedback on the form. A third test wasn’t performed used due to a miscommunication.
Due to this test, minor adjustments were made to the travel sheet based on the comments that were given. Some clarifications had to be made on the exact description of the process steps. These textual clarifications mainly had to do with unclear or multi-interpretable descriptions of process steps.
A face validity check was performed on the data from the test measurements. No unrealistic data, like extremely short, long or time overlapping process steps, were found. The data was examined by the chair of the committee, the departmental manager and supervisor from the MBA faculty.
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See appendix 2 for the final travel sheet. The measurement plan was approved by the working group and data collection was started in 30 patients. No formal power calculation was performed to determine the amount of measurements for this project. This amount of measurements was regarded sufficient by the experienced members of the MBA faculty.
Data collection
Many efforts were made to successfully acquire data with the travel sheet. These efforts are presented in chronological order:
First, a general educational lecture was given to the medical staff as well as radiation therapists.
An email and a reminder was send to the whole department to increase the attention of the professionals.
Medical staff, initiating the data acquisition process, were trained individually on the registration forms.
Halfway during the data acquisition, another email was send to thank participants for their contribution and to further motivate the professionals. In this email, special attention was directed to optimally register the data. This had to be done since at least 5 forms were not filled in properly, mainly coming from the Almere department. These measurements were removed from further analysis.
For the same reason, a small task force was installed on the location of Almere. This task force motivated people to fill in the forms accurately. This group consisted of people from outside the working group, but involved in the treatment preparation phase of the OSS.
The project manager personally instructed new employees to actively take part of the research project on several occasions.
During the meeting, working group members were asked to invest time in trying to increase the number of included patients.
At the last part of the acquisition period, the committee chair informed the medical doctors personally about the status of the project again encouraged them to include patients.
Data acquisition was foreseen to take 2 months. Despite all efforts, it took finally about 5 months to finally complete (July-November). Many reasons for the delay can be found: forms were forgotten or could not be found, patients refused to participate or were considered improper to take part in the project. Despite all efforts on educating the staff, still some employees were not aware of the project and forgot to include patients. On top of that, many OSS time slots were not used in the summer period.
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V Analyze
Introduction
After the collection of data was completed, the Analyze phase started. The OSS process is diagnosed mainly by using a value stream map. The value stream map, presented in the next paragraph, gives insight in the bottlenecks and most time consuming steps of the OSS process. In essence, it is a flowchart that is supplemented with process metrics. These are often processing times and waiting times.
The project benefits (as described in the project charter) will be recalculated in the
successive paragraph based on the acquired data. In the final paragraph of this chapter, the performance of the process is benchmarked against the two other radiation therapy
departments in the Netherlands.
Diagnose the current process; the value stream map
SV MD 0:23 (0:01-0:52) CT-scan 0:16 (0:06-0:40) SV field setup 0:15 (0:05-0:50) Prepare plan 0:39 (0:10-1:58) Check plan 0:22 (0:07-1:20) Prepare field setup 0:13 (0:02-1:00) Field setup MD 0:17 (0:01-0:45) Prepare CB/TV 0:01 (0:00-0:15) Check CB/TV 0:06 (0:01-0:20) Treatment 0:18 (0:05-1:11) W1 0:11 (0-0:40) W2 0:18 (0:05-0:50) W3 0:06 (0-0:45) W4 0:08 (0-0:45) W6 0:10 (0-0:42) W7 0:12 (0-0:50) W8 0:01 (0-0:15) W9 0:11 (0-1:16) W10 0:52 (0-1:40) W5 0 (0-0:05) Process step Mean (Range) Process step Mean (Range) Wating time Mean (Range) Wating time Mean (Range) Patient Patient Process step Only in case of supervision on MD Mandatory process step Consult MD 0:29 (0:16-0:52) Shape Color Legenda
Figure3: The value stream map of the OSS process
The results were discussed with the members of the working group. These were the most important findings:
The OSS process consists of in total 11 steps, TPT is 4:36 hours on average with a maximum of 7:00 hours,
Between every step of the process, waiting time occurs. Waiting time was 1:33 hours on average with a maximum of 3:32 hours,
A large spread was found in the performance of the process steps, maximum range was 1:48 hours. This occurred in the step in which the treatment was calculated.
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Most steps were performed in a serial manner,
Largest waiting times were seen between the transition of responsibilities between the two disciplines,
Largest processing times were found in the preparation and supervision of the treatment by the medical staff.
The number of radiation therapist involved in the process ranged between 3 and 10+. In 20% of the patients 10 or more radiation therapist were involved.
The most time consuming processing and waiting steps (on average) are presented in the Table 1 and Table 2 respectively:
Rank Description Step number PT (hours)
1 Prepare treatment plan 7 0:39
2 Consult MD 1 0:29
3 Supervision after consult 2 0:23
4 Check treatment plan 8 0:22
5 Treatment delivery 11 0:18
Sum PT of top 5 2:12
Percentage of total PT 69,0 %
Table 1: The most time consuming processing steps (averages)
Rank Description WT number WT (hours)
1 Waiting for treatment 10 0:25
2 Waiting for CT-scan 2 0:18
3 Waiting for plan check 7 0:12
4 Waiting for supervision 1 0:09
5 Waiting for SV after consult 6 0:08
Sum WT of top 5 1:14
Percentage of total WT 79,7 %
Recalculating the business case
Now that valid data is available on the performance of the process, the anticipated financial benefits can be recalculated to improve its realism. In the project charter the estimated throughput time was 5 hours. The average throughput time in the group of 30 patients was 4:36 hours, which is close (less than 10% below) to the estimated TPT. If the anticipated results of the project, a TPT of 2:30hours, remain the same, the financial benefits are likely to 10% less too. First, a 55,000 euro reduction was estimated. Based on the data, a 50,000 euro reduction is more realistic.
Another insight the acquisition of data gave was that not all available time slots, were used by patients. No data is available on the exact use of these time slots, as the sampling period was only the summer. This data could have contributed to an even more realistic financial benefit estimation.
Benchmarking
To be able to benchmark the performance of the department, two other hospitals were contacted. First, the radiation therapy department of the LUMC in Leiden was asked to share their performance. No exact data were available, but patients were scheduled in a period of about 3 hours.
The radiation therapy department of the UMCU in Utrecht can treat up to 4 palliative patients a day and whole treatment process takes about 3 hours.
From the benchmarking, it is clear that the OSS procedure at the AMC takes much longer than in the two other hospitals LUMC and UMCU. Taking this fact into consideration, a reduction to less than 3 hours as anticipated in the project charter, seems feasible.
Identifying potential influence factors
In the second part of the Analyze phase, factors influencing the current performance of the process were identified. In Lean Six Sigma, this is an important step, as a researcher is expected to keep an open mind and consider all options, however unlikely.
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Three different methods were used to come to broad range of factors affecting the length of the One Stop Shop procedure:
The Ishikawa diagram,
An autopsy,
Lessons from analogous situations.
The different techniques and their results will be described below.
The Ishikawa diagram
An Ishikawa diagram, also called ‘fish bone diagram’, is a technique to cover all categories of influence factors. In Figure 4 an example of a “fish bone diagram” can be found28.
Figure 4: An example of a Fish Bone Diagram28
The diagram was developed by Kaoru Ishikawa28. This helps in preventing missing an entire type of factors. In this study the four Ps were used: Policies, Procedures, People and Plant (or technology).
This technique was applied to all processing and waiting steps of the OSS process that took more than 10 minutes on average. Three hours with the multidisciplinary working group were spent on finding the root causes. In the end, 64 influence factors were identified using this technique. An overview can be found in appendix 3. The major insights arrived from this technique are:
A large spread in knowledge and experience is present in the group performing the One Stop Shop,
No formal educational program is available to train professionals to treat OSS patients,
Training and education is performed on real patients,
Every radiation therapist on the department should be able to treat a OSS patient outside working hours. Due to that fact, an incentive exists to select professionals with a limited amount of experience to perform the procedure. This is the only way to gain experience.
Important steps in the procedure are planned during coffee and lunch breaks.
Autopsy
An autopsy is a technique in which a close examination is performed of bad examples18. In this study, patient with case number 25 was examined. The patient was selected for this detailed investigation because of an extremely high throughput time of 7:00 hours. Remarkable were the following characteristics:
The patient had a consult with an inexperienced intern,
Supervision was performed by the head of the department; a medical specialist that treats a limited amount of patients per year (relative to other medical specialists),
Not all information to be able to prepare the treatment was available in the medical record,
Patient was treated on three different treatment sites, which is a protocol violation (2 locations is set as maximum in the treatment protocol),
Dose calculation was performed with treatment planning and took an exceptional 1:45 hours, possibly caused by the previously described protocol violation,
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Treatment preparations arrived too late on the treatment unit. Therefore, the patient could not be treated on his time slot but the moment space was available on the treatment unit.
Lessons from analogous situations
At the time the data acquisition for this project was running, a Lean project was initiated to improve the workflow of patients treated with a curative intend. This project started with a whole week analyzing and improving the departmental workflow with a group of 12 people, representing all professions present at the department. The chair of the OSS working group took part in this week. Insights coming from this project are highly applicable for the OSS project. All influencing factors found in this Lean week can be found in the project matrix. Some important insights coming from this week were:
No incentive to speed up the process is present in a system in which the treatment date or time is fixed at forehand.
Every transition of the responsibility for a patient from one professional to the other automatically creates a queue.
Starting the preparation of a treatment with insufficient information creates a lot of extra and/or rework in a later part of the process.
.
To conclude
Finally, an extensive list of potential influencing factors was created after all three techniques were performed. To be able to create overview, the influencing factors were written down in a process matrix which can be found is appendix 3.
VI Improve
Introduction
The first part of the Improve phase is to identify, within the extensive list of potential influence factors, the most important ones (the Vital Few). This was done in two steps. First, a questionnaire was held under the medical staff of the radiation therapy department. In this questionnaire, doctors were asked to give their opinion on different aspects of the OSS procedure. Questions were asked about the length of OSS, the techniques used to perform the OSS and the sustainability in future of the OSS. The answers provided a context for the direction in which the OSS should change. Complying improvement actions to the (average) opinion of the medical staff improves the likelihood of success as well as the sustainability of the results of this project.
Second, the total list of influencing factors was reduced to a list of influence factors that are highly influential and changeable in the setting of an academic hospital. The factors were determined in during a working group meeting.
Based on this short list, together with results of the questionnaire, a redesign was proposed and discussed with all relevant stakeholders. After achieving consensus, all involved
professionals (doctors and radiation therapists) were educated and trained to perform the redesigned procedure.
The redesigned workflow was tested in a pilot study of 5 patients to scientifically prove its effectiveness. Results were statically tested comparing the outcome of the pilot with the results of the historical performance of the OSS.
The questionnaire
Guidance for future improvements was needed to continue with the improvement phase. To be able optimally define possible actions for improvement, a clear vision on the (future) developments within palliative radiotherapy was desirable. Therefore, a questionnaire for the medical staff was designed and performed. Within this questionnaire, the medical staff could give its opinion on the performance of the current process. People were also asked to
31
give their opinion to what extent the procedure is sustainable in future. This questionnaire was believed to a) improve and enlarge the list of influence factors that was determined in the Analyze-phase, and b) enhance commitment of all people involved with the project. The latter is very important as an outlook to change often leads to resistance.
All 24 doctors working on the department were invited to take part in the questionnaire. In the end, 50% of the doctors completed the questionnaire. All results can be found appendix 4. The most important findings were:
The toxicity of the radiation therapy treatment is considered low.
Most doctors considered the current procedure on the department as “a substantial burden for the patient”.
More than 80% (10/12) of the doctors would be satisfied if the OSS procedure would take less than 3 hours. 2 out 12 doctors think that the procedure should not take more than 2 hours.
Treatment can be prepared either by using a manual calculation or using a dose modeling program. Most doctors (>80%) think that both options should be available for preparing the OSS treatment, however the manual calculation should remain the default technique to be used in this setting.
Identifying the highly influential and changeable factors
The list influential factors created in the analyze phase formed the basis for identifying the
Vital Few (very important) influence factors. Whether an influence factor is important, is
determined by its anticipated effect size, and its changeability. That is, only influence factors that determine a great deal of the CTQs are selected. But out of these influence factors, only those are selected that are changeable. For example, although not allowing interns and residents from participating in the process will greatly reduce processing and throughput times, it will also negatively affect the educational task of this hospital, and is therefore an unfeasible step. Only influence factors with great effect size and changeability are used for actual improvement actions.
These factors were selected in a working group meeting based on the value stream map as well as the statistical performance of the OSS process. Not all factors could be proven statistically to be highly influential. For that reason, in this project, it is decided that the significance of the influence factors is not tested beforehand. Instead, a new process will be designed. This new process is, for the sake of following DMAIC, considered the one-and-only influence factor (which is a binary variable: either the new process is implemented, or it is not). The relevance of this influence factor will be tested by performing a pilot study, and measuring whether the CTQs have improved with respect to the original measurement. Because factors would be tested in pilot study later, this methodological flaw was accepted by the working group. Moreover, not causing any more delays with statistics, greatly helped to maintain enthusiasm amongst the project team. Below the short list of influential and changeable factors:
The number of radiation therapists involved in the process:
o No personal responsibility is felt for a patient treated by 10+ professionals
The serial performance of the process.
The fixed treatment time slot in the afternoon.
The fixed CT time slot in the morning.
The range in the of experience level of professionals performing the OSS.
The fact that no educational program is present, and that therefore, a negative selection based on a low experience level occurs.
No incentive for a smooth and fast workflow is present.
Supervision as well as the use of treatment planning in the process had high influence on the throughput time of the OSS. These factors were considered unchangeable since changing the factors would violate one of the missions of the department (delivering high quality
treatment in an academic setting)
Redesigning the workflow of the OSS
Based on the short list of highly influential and changeable factors, with results of the
33
on different occasions (formal and informal meetings). The redesigned workflow is presented in figure 5.
Consult MD Supervision MD CT-scan RTT 1+2
Supervision MD Prepare plan RTT 1 Check plan RTT 2 Prepare field setup RTT 1+2 Field setup MD Prepare CB/TV RTT 1 Check CB/TV RTT 3 Treatment delivery RTT 1+3
Waiting time Waiting time
Mandatory step of supervision Only in case Patient Patient Color blue Legenda Color grey
Figure 5: Redesign of the OSS workflow
The major changes in comparison with the previous workflow are:
A team performing the OSS is formed at the beginning of the day
The number of professionals in the process is reduced significantly
o A maximum of three RTT’s are involved. Transferring the responsibility and case to other professionals is reduced to a minimum.
One radiation therapist is responsible for the workflow of the patient. This RTT is present in every step of the process.
Radiation therapists performing the OSS are selected based on a sufficient skills level. If the pilot succeeds, this knowledge level will be ensured for all radiation therapist by creating an educational program.
In the new design, steps are identified which could be performed serial.
A dedicated working space was determined to perform the largest part of the
procedure. A benefit of this working space is that team members now know where to find each other. Therefore, the number of waiting times could be reduced
The pilot study
After achieving consensus, all involved professionals (doctors and radiation therapists) were educated and trained to perform the redesigned procedure:
All radiation therapist specialized in treatment preparation received a personal instruction by the members of the OSS working group.
All residents of the department, performing most OSS procedures received a 1 hour interactive presentation showing the results of the project as well as an instruction for the pilot study.
All radiation therapist received a similar but shorter presentation on their monthly meeting.
The whole department was informed about the pilot study by email in which an extensive description of the project was made.
Five patients were included in this pilot in January 2017. Three patients could be regarded as standard. A fourth patient was treated with a high complex five field IMRT technique wherefore a treatment planning was needed. A fifth patient was treated on an extreme large area. A non-standard dose calculation procedure was needed. Therefore, different experts had to be consulted to be able to perform this (clinical physicist and an expert in IGRT). 3 Patients were seen by a resident and were supervised by the medical specialist. In two of these cases, the resident recently started working on the department. One patient was seen by a medical intern under supervision of a medical specialist. One patient was treated by a radiation oncologist, so without supervision.
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TPT1 WT1 PT1
Mean (hours) 3:00 0:52 2:05
Standard Deviation (hours) 0:31 0:31 0:54
Minimum (hours) 2:10 0:18 1:07
Maximum (hours) 3:30 1:34 3:19
Absolute reduction (hours) 1:36 0:47 0:59
Relative reduction (%) 35% 50% 38%
p-value: non parametric T-test 0.01 0.05 0.02
Table 3: Results of the pilot redesigned process
TPT, WT and PT reduced dramatically. TPT was reduced with 1:36 hours (-35%) on average. The major part of this reduction was coming from a reduction in PT of 0:59 hours (-38%). The WT was reduced with 0:47 (-50%) from 1:22 hours to 0:47 hours. Reductions in TPT, WT and PT were all statistically significant (p=0.01, p=0.05 and p=0.02 respectively).
The number of RTT’s working in the pilot supposed to be 2 or 3 according to the redesigned workflow. Despite clear instructions, at least 4 RTT’s were involved in the process.
With the results of the pilot, the financial benefits can also be calculated. A 2.5 hour reduction was estimated at the start of the project. In the pilot, a 1:36 hour reduction was realized. The financial benefits of the project decreases accordingly from 55,000 euro to 35.000 euro if assumed that professionals cannot add value with other activities in the waiting time of the process. If they are able to do so, the financial benefits of the project will only come from the reduction in PT of 0:59 hours on average. This could potentially lead to a 22,000 euro reduction in labor costs.
1 The TPT is supposed to be the sum of the WT and the PT. In some sub steps of the travel sheet start or end time was not registered and therefore had to be left out of the analysis. Start and end time of the first and last step were always registered properly. Therefore the TPT is the most reliable number.
VII Control
The final stage of a DMAIC project is the Control phase. In the control phase actions are carried out to ensure that the results of the improvement phase will be retained18. In the pilot study, a reduction of 1:36 hours was realized. These results were achieved in a group of patients that was treated under supervision of a medical specialist and had an above
average difficulty to prepare. Therefore, the introduction of the redesigned process on all OSS patients was regarded feasible by the members of the working group.
The redesigned process will be documented in a (updated) protocol. This protocol will consist at least of the following items: in- and exclusion criteria for the OSS, a time schedule for the OSS and a list of roles and responsibilities. A protocol for the OSS was already in place by the time the project started. The redesigned process will form the basis of an update of the existing protocol. After approval by the management team and medical staff, the protocol will be made available on the online quality system of the hospital (Kwadraet). All involved professionals need to read (and sign for it) after the protocol is being published. The first element of the protocol are the in- and exclusion criteria for the OSS. The redesign of the OSS was mainly based on logistic interventions and did not affect the techniques used within the protocol. Therefore, the in- and exclusion criteria for the OSS will not change. A strict time schedule for processing the OSS was suggested by two of the members of the OSS working group. In this schedule fixed time slots for start and finish of process steps will be defined, e.g. consult MD from 9:30-10:00, CT-scanning from 10:00-10:30 etc. etc. The final time slot at the treatment machine will be moved from 14:30 to 12:10. This will ensure that the results of the project will be retained in future.
A third element of the protocol is a description of the roles, responsibilities and the
educational requirements of the professionals involved in performing the OSS. In this part of the protocol expectations on the input and educational level of radiation therapy residents, radiation oncologists and radiation therapist will be written out. This part of the protocol will ensure that it is clear what part of the process is performed by which professional.
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To ensure that the decrease in PT will be retained, an educational program will be set up. This program will enable professionals to practice their skills without having to practice on real patients( which is the case until now). The development and execution of the
educational program will be performed by a working group that is dedicated to continuous education.
The result of the pilot study, together with the protocol and the time schedule will presented in the medical staff meeting of February 2017. In this meeting approval for full introduction will be asked. The full introduction of the redesigned process will be supervised by the OSS working group. This group will keep meeting each other on a monthly basis until July 2017. In December 2017 a review of the process is planned. If necessary, new follow-up moments will be planned for 2018.
The project discharge form was signed by Iris Wanders, the champion of the project
(appendix 1). This means that the responsibility for maintaining the results of the project is formally handed back to the management team of the department of radiation therapy.
VIII Discussion
The throughput time (TPT) of the one stop shop (OSS) procedure was successfully decreased with 1:36 hours from 4:36 hours to 3:00 hours on average. The largest part of the reduction, 0:59 hours, was coming from a reduction in processing time (PT). The remaining part of the reduction came from a decrease in the waiting time (WT) between the process steps. With the results of this project patient satisfaction was improved, assuming a direct relation with TPT.
The reduction in TPT also affects the labor costs involved performing the process. The foreseen TPT reduction of 2:30 hours, which could lead to a 55,000 euro cost reduction on a yearly basis, was not achieved. With the results of the project, at least a 22,000 euro labor cost reduction is feasible.
A further reduction in TPT could be achieved by decreasing the treatment options of patients treated with the OSS procedure. The model based dose calculation takes on average 0:55 hours longer (5:21 hours on average against 4:26 hours for the manual dose calculation) and not offering this option would certainly decrease the average TPT. This option was not taken into consideration since the results of the questionnaire clearly indicated the some patients benefit from this treatment option.
Another, even larger reduction would have been feasible if the competing goal of the department, namely education, would have been ignored. If all patients were only seen by medical specialists, instead of by a resident or an intern first, the procedure would become much shorter. The average TPT of patient treated by residents (or interns) under supervision was 4:54 hours. The average TPT of patient treated only by the medical specialist was 3:45 hours. The extra step of being seen by a resident or an intern first, does not add any value to the patient. Therefore, this step could have been eliminated if the process would have been optimized while ignoring the strategic focal point of education (eliminating non value adding steps).
LSS was proven to be successful in optimizing the workflow of the processes in the field of radiation therapy. The academic environment however, limits the possibility to reduce the
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impact of important influencing factors. LSS does not seem to facilitate optimization of processes with multiple criteria as was mentioned in literature by J. Antony et al26.
LSS did enable improvements beyond the obvious and added value in different parts of this improvement project. This statement will be supported with two examples below. The underlying principles of the improvement technique, as described in the introduction chapter, will be recalled along with the examples.
The results of the improvements tested in a pilot were very positive. The redesigned process was based on insights coming from the group meetings in the analyze phase. Different important influencing factors, identified with the Ishikawa diagram, were not foreseen beforehand. E.g. the fact that there is a selection of professionals involved in the based on a low level of skills and knowledge. This deeper insight was only recognized after some hours of group discussion and reflection. This example is an illustration of the Lean Six Sigma principle “improvement based on understanding the causes”18.
Important ideas for redesigning the process came from working group members and were enabled by the structure of LSS. The use of a dedicated area to prepare the OSS for instance, was brought up in the Improve phase. The redesigned process is likely to have looked different without the use of LSS. This example is another illustration of the Lean Six Sigma principle “improvement based on understanding the causes”18.
Some parts of the project were challenging. The inclusion of patients was difficult, despite the fact that the project was running in an academic setting in which one might expect a natural motivation to collaborate in research. Numerous attempts were made to improve the inclusion. In the end, the acquisition period took 3 months longer than was planned. Despite intensive communication, the pilot was never performed completely according to the redesigned process. The number of radiation therapists in the process remained high. No patient was treated by 2 or 3 radiation therapists as was suggested by the redesigned
workflow. On top of that, most patients did not see one of the radiation therapists on the treatment machine that also performed the CT-scan. Results might have been better if the protocol was followed completely, but no data is present to support that statement.
It is difficult to answer the question whether other improvement techniques, like the ones mentioned in the introduction of this thesis, would have performed worse, equal or better on this project.
The data based diagnosis, coming from the Six Sigma principle “Data-based diagnosis before
solution attempts”18, gave insight in the most time consuming processing and waiting steps of the process. On top of that, factors influencing the length of the procedure were easily identified using the acquired data. The broad search for influential factors prevented tunnel vision. It is questionable if these insights were also gained with less quantitative procedures like Total Quality Management (TQM) or Business Process Reengineering (BPR).
Another positive aspect of the Lean Six Sigma methodology is that is explicitly requires involving a large and multi-disciplinary part of the department, directly or indirectly, in the improvement process. Colleagues were actively asked to participate in quantifying the problem and were involved in finding solutions to the problem. This is likely to enhance the awareness of the problem of the OSS and the motivation to contribute to change. Neither the sense of being involved, nor the motivation to change, was quantified in the project. However, it is not likely that other improvement techniques like BPR or Scientific
Management (SM), with a more top-down character, would have performed better.
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Appendix 1:The original project charter
Lean Six Sigma templates by IBIS UvA (see acknowledgement)
CHARTER
1Summary Summary of the project
2SIPOC Define a process by providing a high-level process map
3Benefit analysis Identification of potential benefits of the project for customers and the business
4Project details Type of project, deliverables, conditions, scope
5Organization Project organization: champion, review board, team
DEFINE
6DEFINE: DMAIC 0 Project review: Define (DMAIC 0)
7Stakeholder analysis Analyse the political forcefield surrounding the project
8Stakeholders: Influence vs. Stake matrix Identify potential allies and opponents
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Appendix 1:The original project charter
Project title:
Reducing the total treatment time of palliative patients treated within a One Stop Shop
Process or product to be improved:
One Stop Shop Palliative treatment
Objective of te project:
Daily two dedicated time slots are available for patients who need (semi)acute palliative treatment for e.g. spinal cord compression. Treatment is often (very) uncomplex but unfortunately time consuming. The aim of this project is the reduce the current workflow of 5-6 hours to less then 2 hours (current best practices below one hour)
Anticipated benefits:
Reduced total treatment time improves patient satisfaction and will reduce the manhours spent per patient by healthcare professionals substantially.
Start date: Anticipated completion date:
tbd tbd
Black belt Green belt(s)
Martijn Kamphuis Yvonne da Lima
(coordinator zorglogistiek)
Approvals
Black belt: ABS
Green belt: Yvonne da Lima
Supplier: Michel de Haan
(responsible for time of BB / GB)
Champion: Iris Wanders
(problem owner)
User: in future: Coen Rasch (needed for benefit realisation)
