Methods
Lean Six Sigma is a combination of 2 improvement processes and is embraced by large business and government entities with the goal of improving efficiencies, reducing waste, decreasing errors, and generating cost savings.19 The first improvement process, Six Sigma, is a statistical concept with the goal of producing no more than 3.4 defects per million opportunities.20Using specific tools, Six Sigma identifies the cause of the problem to help develop effective solutions. Six Sigma also helps uncover defects and problems by using a standardized and systematic method for each process improvement project in a sequence of steps known as DMAIC (Define, Measure, Analyze, Improve, and Control) to ensure a defect-free product at a rate of 99.99966%. Define, the first step, contains a written statement defining the problem and the goals; Measure scrutinizes the current baseline of the project in measureable data to identify possible contributing factors; Analyze uses data and tools to understand the cause-and-effect relationships in the process; Improve uses creative developments and changes that lead to process improvements; and Control takes measures to ensure the improvements are implemented, reliable, and constant.
Although slightly different but complementary, Lean focuses on streamlining improvement processes by identifying and eliminating waste that has little or no value to the customer. The 8 most common forms of waste are identified through the mnemonic DOWNTIME (Defects, Overproduction, Waiting, Not utilizing human talent, Transportation, Inventory excess, Motion excess, and Excess processing).21 When both Lean and Six Sigma are used together, the synergistic effects have a powerful impact on the complete quality improvement process and yield consistent reliability. The combined process then includes several methodologic tools for systems redesign, including root-cause analysis, defining waste barriers, measuring current and expected performance, analyzing the data collected, improving the target process, and controlling the improvements. Though already existing and used within the VA system, Lean Six Sigma training was included as a mandatory component of new employee orientation in a memo issued in August 2015 from the assistant secretary for human resources and administration (VA access-only memo VAIQ 7595924).
Root-cause analysis was accomplished using the “5 Why” technique adapted into Lean and Six Sigma from the Toyota Motor Corporation. For example, the question “Why do patients miss appointments?” was asked 5 different ways, and it was determined that many patients lacked transportation, some were not able to reschedule at the time they called to cancel their appointment, those with multiple same-day appointments at the tertiary medical center were not able to wait to schedule a follow-up appointment for fear of missing or being late to their next appointment, and others were placed on recall lists with appointment reminders that failed to accomplish the purpose of self-scheduling by veterans. Thus, the common denominator and answer to the question “why” was that there was no tracking system in place to identify and reschedule missed follow-ups, and before employing a dedicated coordinator, no one accountable for the process (Figure 1).
Wasteful barriers to efficiency were examined with particular attention to the rescheduling process. Rescheduling produced immediate duplication of work for scheduling staff and increased wait time for future appointments. There was potential for additional health care expenses related to costs of late and progressive salvage treatment or for less-than-timely correction of HNC treatment sequelae, such as scarring, lymphedema, or dysphagia. Ear, nose, and throat providers were concerned about missing occult recurrence or residual cancer.
In 2013, the Lean Six Sigma process was used again to critique efforts by the CCC to identify and track HNC patients. One suggestion was to automate the process, and the Information Resource Management (IRM) office was contacted via work order to explore options for mining CPRS data. Working with a committed health information analyst, further discussion was aimed at pulling in additional data that would simultaneously track required posttreatment laboratory results and imaging. It was decided that a secure dashboard format would provide greater utility than would an online report that the CCC had to request and generate daily.
Integrated technologist Stephen Few defines a data dashboard as “… a visual display of the most important information needed to achieve one or more objectives; consolidated and arranged on a single screen so the information can be monitored at a glance.”22 The Head & Neck Cancer Tracking Dashboard (HNC Dashboard), designed by the IRM analyst, queries the VA Corporate Data Warehouse each night to identify all patients recently diagnosed with HNC by examining outpatient visit and inpatient discharge International Classification of Disease (ICD) codes entered by providers when coding encounter notes in CPRS. It also adds those with a HNC diagnosis in the VistA problem list and the HNC pathology department Systematized Nomenclature of Medicine (SNOMED) codes (Figure 2).
The automated ENT cancer tracking dashboard prototype debuted in 2014, but several months of trial and error took place to reanalyze ICD codes and narrow the list. The dashboard underwent multiple tests to ensure accuracy. Identified patients are presented using an interactive report hosted on a secure SharePoint (Redmond,WA) site, which reduced the risk of a data breach as access requires multi-authenticated user identification from a VA computer.
Another characteristic of the dashboard’s format is the ability to add custom features as needed. Several features now included in the dashboard are location of residence, diagnosis date, ICD code, date captured in the tracking system, most recent ENT clinic visit, future scheduled ENT clinic appointment, date of last thyroid stimulating hormone (TSH) laboratory test, and date of last position emission tomography scan. In addition, cancellations, no-shows, and patients overdue for TSH testing are highlighted in bold. Highlighted fields alert the CCC to reschedule patients in a timely manner and can alert providers to order needed follow-up tests and procedures.
Among the merits of the ENT cancer tracking dashboard is ease of use. The CCC uses a simple ABC acronym to describe utilization:
- A—added: The CCC daily edits new patients added to the dashboard with a HNC diagnosis. Several times recently the CCC saw a new diagnosis before the provider had been notified by pathology of biopsy results (Figure 3).
- B—browse: The dashboard format allows for rapid perusal of critical information at a glance (Figure 4). Recent labs and imaging can be discussed with providers immediately or at weekly ENT team cancer update meetings. Notification to clinicians can be rapid if the results show suspicion for residual/recurrent disease, a second primary site, metastasis, or there is need to notify the patient’s primary care provider to treat elevated TSH levels (hypothyroidism incidence after head and neck radiation is reportedly as high as 44%, with most patients being asymptomatic or simply fatigued).10,23
- C—check: Appointments are checked for those in the future, cancelled without rescheduling, or no-show dates. Empty fields under the “Next ENT Appointment” header alert the CCC to reschedule a follow-up appointment within NCCN guidelines. Alerting providers to upcoming surveillance appointments allows timely coordination with other care providers and departments, including speech pathology, nutrition, audiology, and social work. The “ENT Recall Date” has a unique time-sensitive feature and will visually display a bold type font when ready to be scheduled for a physical appointment (Figure 5).
