Healthcare Purchasing News consulted with a team of experts to offer their tips on how to make it happen.

For Terry Cox, MA, MS, FAHRMM, CMRP, director, supply chain services, Texas Children’s Hospital, Houston, it’s a simple equation: "By selecting key players that will benefit from the improved outcome. It is most important to have people that are engaged in this process throughout."

But for James Smoker, MPA, CMRP, now retired director, materiel resource services, WellSpan Health, York, PA, it requires organizational pervasiveness.

"It requires top-down commitment to change and to view the implementation as a long-range culture change to break down the cultural and professional silos that exist in many healthcare organizations," Smoker told HPN. "The siloed managers tend to feel that anyone outside their discipline cannot understand the issues they deal with. The old adage, ‘familiarity breeds contempt,’ needs to be refined to ‘breeds understanding.’ Part of it is to be visible. Walk in another’s shoes and you, too, will get sore feet.

"Typically, supply chain management’s interest with the clinical folks starts when a supply walks in the back door or a new GPO contract opportunity comes up," Smoker continued. "You need to get the procurement and contract team members into clinical practice areas to understand their issues. What’s high priority? What clinical folks clearly want. We have a success story at our community teaching hospital. The perioperative and cardiovascular contracts administrator, Mark Triller, works with doctors differently than most. He isn’t afraid to approach them. If we have problems with a particular vendor he’ll ask them to stop using their products for a week to influence the rep to load pricing properly. He’s worked with surgeons in the heart center and actually had one cardiologist come to him and ask what pacemaker they were using this week. He’s in scrubs there every day. They see him as a business partner rather than an antagonist. The closer we can get to our customers they will understand our issues in working with vendors and will understand our world."

Here’s what others had to say.

The "right" people would certainly include representatives from the department(s) who use or will be affected by that item, as well as an array of supply chain and administrative/financial folks who can speak to the costs and processes involved in obtaining/using that item. In some scenarios with expensive supplies, it might be well to include a reimbursement specialist who can speak to potential impact (positive or negative) of that item from a revenue perspective. Many hospitals also feel that having a clinical committee member who is part of the supply chain organization is helpful and can be an effective liaison between the two perspectives.

Key requirements in choosing right people to participate in lean and Six Sigma process include: Constancy of purpose and a strong desire for change; deep leadership commitment and accountability; dedicated resources and defined program infrastructure; process management skills; understanding of prioritization of projects and activities; experience with Kaizen/Rapid Improvement Events; and ability to sustain focus.

The best way to adopt Lean management and Six Sigma principles is to invest in the training of employees and building a culture that will breed these principles in every aspect of supply chain management. The two main mechanisms hospitals can establish Lean and Six Sigma cultures in their supply chain management include:

1. Hiring outside industry Lean and Six Sigma experts to train their employees. This approach helps bring experience from outside industries to help train hospital employees, introducing fresh ideas and concepts that are often difficult for the hospital to implement at rapid pace. The only drawback to this approach is that the external experts’ lack of exposure to the clinical environment can sometimes make it hard to instill many of their standard practices in the healthcare arena.

2. Train existing employees to help improve internal processes. This approach works well when it comes to familiarity with the clinical arena. However, in many instances there can be a level of fatigue associated with having worked in the clinical environment that results in a resistance to accept changes from a non-healthcare environment.

The first step is to make sure the senior leadership understands and supports the program. Lean Six Sigma needs to be driven and supported from the top down. Your practitioners – Black Belts – should be the cream of the crop, if you will. The black belt role should be constructed to be a career accelerator. The ideal candidate is a person with a few years of experience n the business, that is highly regarded by his/her peers and by leadership. This person needs to want the job, not be assigned to it. A black belt does not need to be the best statistician or have an engineering degree, but does have to have some math skills. The person does need to have personal confidence and be able to communicate and listen. A black belt is a full time job. Having a person, be responsible for a business line and be a black belt simply does not work.

The part-time Lean Six Sigma role is the Green Belt. This person should also be a volunteer. This person is not as schooled in the tools. A green belt keeps his/her day job but drives smaller, less complex projects.

Both Lean Management and Six Sigma require customers, stakeholders and experts to be members of any and all project teams once a Lean or Six Sigma project has been selected. However, these individuals will all need extensive training (Black Belt, Green Belt and Yellow Belt) in these advanced methodologies before they can let loose on any project. The project will be led by a Black Belt who has extensive training and experience in these disciplines.

Lean demands a representative cross section of participants from all operational areas affecting workflow who are thoroughly familiar with the process(es) in focus Once waste has been identified and the process(es) modified accordingly, drift is less likely to occur and requires only periodic process review to maintain gains. Six Sigma projects are much more rigorously planned, organized and implemented, requiring a broad spectrum of leadership and key stakeholder participation. Program participants are selected from a much more granular palette of skills and must be able to provide more focused and structured input.

Facilities lacking any expertise in Lean Six Sigma are well advised to select a consultant to help them begin the process, although an understanding of the concepts will enable many to use them well even without a formalized approach. The advantage of a visible and personable expert as facilitator is the focus and validation such a role can bring to cultural change. It may only be necessary for senior leadership to work with a consultant, if the requisite commitment is there and existing leaders will be "working champions" for the change. But clear, consistent and visible commitment of leadership is crucial to successful adoption of Lean Six Sigma methodology and is the requisite first step to success.

It is important to note that this should be treated as a departmental initiative. There needs to be executive sponsorship and an organizational agenda that drives the activities so it’s not carried on the shoulder of the director of materials management. Organizations should approach this as a top-down initiative, not a bottom-up initiative.

Broadlane helps organizations create an annual work plan that outlines what they should to accomplish over the course of the year, and this is tied to their budgetary savings efforts and initiatives. Every month our clients know what they are going to be working on, as well as how much progress they’ve made against the goal and what the gap is. Individuals are held accountable to each initiative, and collectively as a team, the group is responsible for the overall organizational goal.

Adoption and implementation of Lean Six Sigma principles is best done when driven by a management improvement or process improvement department, which is looking at the goals of the organization and prioritizing activities that will help the organization achieve these goals. This ensures that the initiatives – and the man-hours and effort going into the initiative – have administration’s support. The process improvement group would then provide direction and serve as project manager for the initiative. Trained, experienced Lean and Six Sigma personnel have a storehouse of methods to select from where decisions are driven by data rather than speculation or strong arming, and follow a defined process whereby each process step is completed only when a checklist is completed. This tollgate or checklist process ensures that the steps have been completed and accepted by project managers, which may include administration.

For those healthcare organizations that do not have a process improvement department, gaining some amount of training in Lean and Six Sigma, as well as project management, before undertaking an initiative is highly advisable. Many teams fail because the members do not have proper training, the initiative is not supported by administration, and team members have conflicting priorities. Training can be achieved through online courses, local universities, reading books on the subject, employing trainers, speakers, or consultants, and seeking advice from peer groups. It is important to select improvement initiatives that respond to the voice of the customer, can be supported with data, and align with the organization’s goals.

To begin a Six Sigma project, search information on the "house of quality" – this tool translates the customer’s wants into what we are doing about the wants and how well we are doing it, identifying areas for improvement. Root cause analysis is both a tool and an activity that almost cannot be done enough in process improvement projects. In both Lean and Six Sigma initiatives, root cause analysis is an activity that must be performed, and performed thoroughly, for sustainable success. A recent case of root cause analysis (for stat calls from the OR to the SPD department) indicated that the number one reason for STAT calls was that product was pulled from the storage shelf if the sterile storage area of the OR, not used, and placed in the OR’s supply cabinet. Had the organization increased the PAR levels as the OR requested to solve the problem, the root cause of the problem would not have been addressed and the accumulation would have continued. What appeared to be usage was, in fact, a stockpile of unofficial inventory.

The team make-up for a Lean or Six Sigma project can influence the results of the initiative. A well-trained project manager will see the need to include representation from such diverse areas as IT, Finance, Clinicians, Materials, Value Analysis, Purchasing, Facilities, Management Engineering, Accounting – even Groundskeeping and Volunteers. The team should not hesitate to add members as processes are dissected and areas are uncovered with which the team is not intimately familiar.

Both a materials management information system specialist and a scrub tech can play key roles in developing current state flow diagrams, gathering data, performing root cause analysis, and brainstorming improvement ideas. The key to selection lies in including personnel who are interested in the improvement process – perhaps those who have sought additional education or have asked for increased responsibilities. Putting naysayers or closed-minded personnel on teams will not do much to help the team achieve its outcome, while building strong teams with willing and like-minded personnel will further advance process improvement within the organization. Process improvement leads to improved utilization of resources, including the organization’s money.

Adopting a lean management philosophy cannot occur within the confines of any one department. Implementing a Lean process or moving to Six Sigma thinking requires a true culture change. A broad-based change in thinking does not occur overnight and requires support from all employee levels especially from that of the C-suite. Supply chain leaders, front-line clinicians utilizing the products and executives need to be part of a Lean process event. Otherwise, the true value of these principles and the cost savings and quality improvements they offer will not be realized or sustained.

Regardless of the known importance, implementing these principles is by no means easy. Due to the numerous stakeholders involved in the decision process, multiple sources of information and requests, and the complexity of the environment, hospital supply chain managers are often faced with reengineering a complex process without the resources or tools to succeed.

In order to overcome these hurdles supply chain managers must gain support from senior management even to the extent of their participation on committees. This is done by conducting a "value analysis" of the process itself and demonstrating how value analysis, lean management and Six Sigma will support and accelerate the achievement of the financial and strategic goals of the facility.

With senior management support, the supply chain manager must establish specific goals and clearly defined roles for each committee and each member. Also, choose appropriate, multi-disciplinary teams to assure a 360-degree representation of the organization.

Supply chain managers should also work toward achieving as much automation of the processes as possible. An example of automation would be Premier’s Value Analysis solution, ValueAdvisor which automates submission of a product evaluation request; checks for existence of an established contract within the facility; provides tools for data collection and evaluation; alerts appropriate decision makers as to required tasks; automates committee administrative tasks to include status notifications; and puts as much shared knowledge in the hands of the decision makers as possible.

One final suggestion would be for supply chain managers to never give up trying to gain adoption of these principles. The value of implementing these principles is well known in supply chain management and well worth the effort of disseminating that knowledge to the benefit of the entire organization.