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Benchmark Six Sigma Expert View by Venugopal R First of all, let us salute all those who are engaged in protecting us from this pandemic, which greatly includes all the people who are directly or indirectly involved in healthcare activities, under such challenging and trying circumstances. Any views on this forum should never be mistaken as a criticism towards anyone doing such noble service, but as a discussion for learning from the experiences and generate thoughts that could help society as a whole to be better prepared in future. One of main issues that we see across the healthcare systems in the world with the prevailing problem is Muri, which means ‘overwork’, for healthcare workers. It would be unfair to blame the healthcare systems for the excess Muri, based on the current situation, since it is beyond anyone’s imagination. However, under these circumstances it is essential to do everything possible to provide relief to the people who are getting overburdened. It has to be mentioned that there are many efforts being taken by various governments and many volunteers to this effect as well. The three components of wastes viz. Mura, Muri and Muda can affect one another and hence it is important to address all of them together. Very often, we see that Muda is the one that gets most attention. I have tabulated these waste components with some examples and suggested a systemic remedy. It may be noted that this is only a very small representation, whereas there is bound to be many more situations for each category and the solutions may not be very easy to implement always. S# CATEGORY EXAMPLE SUGGESTED REMEDIAL MEASURES 1.0 MURI (Overburden) 1.1 Overbearing tasks Stretched working for direct and indirect healthcare staff Forced to handle excessive number of cases than normal Clear criteria to identify genuine cases who need to be admitted, plus awareness Consider geographical redistribution of staff based on need 1.2 Work related stress Handling patients who are not very cooperative Personal attenders / relatives of patients are not permitted due to risk of infection. This adds burden to the healthcare staff Support the skilled healthcare staff with other inhouse staff who can play the role of personal attenders. Maintain regular contact with patients relatives and obtain oral assistance 1.3 High risk tasks Frontline healthcare staff are at high risk of being exposed Continued awareness and providing equipment to staff. Ensure Routine 5S in workplace. Plan staff rotation on high risk area to prevent prolonged risk to anyone 2.0 MURA (Variability) 2.1 Materials related For materials required by healthcare staff, mismatch between requirement and availability Variation in the quality of the materials Material planning exercise to be done at treatment centre level and at regional level Have standards for each item and centralized compliance monitoring Establish authority who understands the risks to decide on use any material that doesn’t meet the standards in case of emergencies 2.2 Methods related Differences with respect to diagnosis, treatment approach, handling, duration, and conditions within and between treatment facilities. Standards for all methods with frequent updating and compliance monitoring by a central organization. Frequent sharing and synching of best practices across centres 2.3 Manpower related Unpredictable variation on day to day patient count Variation in knowledge & skills among staff State level planning for potential patient turnover and necessary treatment facilities Adopt buddy system to quickly orient staff and reduce knowledge variation 2.4 Machines related Critical equipment not functioning or functioning with variations, especially during emergency situations – leading to waiting or treatment deficiencies Equipment availability both in terms of numbers and through predictive maintenance 2.5 Measurements related False positives / False negatives on the screening tests. Dependency on sampling for screening evaluation MSA on the screening measurements to understand the measurement reliability and improvement actions Application of different sampling methods like stratified sampling to obtain realistic density of the problem 3.0 MUDA (Wastages) 3.1 Transportation Transporting patients for various requirements - Testing, ICU. Transporting of equipment across centres Study transportation data to review the facility layout for optimizing movements Consider creating ‘self-sufficient’ zones based on cost-effort-benefit analysis 3.2 Excess Inventory Excess stock of medicines that do not get consumed for long Large number of patients queuing up for being attended at various stages Test requests / reports piled up Value stream and Kanban methods could help in streamlining the processes and minimize inventory 3.3 Excess movements Healthcare staffing having to move about within a centre for various activities. Too many movements required by physicians and other healthcare staff while examining / treating patients Lay out optimization, maximise communications, review positioning of facilities Workplace management – 5S practices 3.4 Waiting time Patients waiting for getting admitted, seeing physician, tests, reports, discharge etc. Physicians waiting for test reports Many of the solutions for other wastes will help to reduce waiting times. Reasons for the waiting time have to analysed whether it is a result of an inefficiency from another process – to decide the best options for solution 3.5 Over processing Assigning more staff than required for a patient Keeping a patient under care more than required Doing unnecessary diagnostic procedures Patients have to repeat the same information multiple times Expectations at each stage need to be understood well, so that both under processing or over processing should be minimized / avoided Ensure patients inputs are recorded and the same file is maintained 3.6 Over production Preparing for a patient too much in advance Define preparatory lead time for effective & efficient preparation to receive a patient 3.7 Defects Wrong diagnosis, administering wrong medicine, improper dosage, mix-up of reports etc are some serious defects Other defects are also possible such as skipping a step during an clinical test, missing out an instrument on surgical case cart Training & certification, checklists, software-controlled protocol 3.8 Talent unutilized Feedback / suggestions from junior and supporting healthcare staff not considered Best practices between individuals, treatment centres not captured Institute and encourage Kaizen system, encouraging all staff to provide suggestions and best practices. Reward & recognition schemes