Lean Six Sigma in Health Call Centers

By Sherry Smith, RN, MSN, MBA

August/September 2009

The economic crisis is affecting numerous industries across the nation.  Almost daily, we are exposed to news about layoffs, tightening credit markets, bankruptcies, bailouts, and their implications for the future.

Healthcare, and more specifically healthcare call centers, are not immune to the trickle down impact.  Medical call centers have typically been viewed as cost centers and, therefore, are now more than ever at risk for closer scrutiny.  While most organizations might be inclined to slash positions, the opportunity exists to focus on customers and processes that add value to the telephone encounter.  Elimination of waste will create greater efficiency in call processes.  In turn, excess capacity will open an opportunity for increased value-added activities that increase customer satisfaction.  Implementing Lean Six Sigma in healthcare call centers, as a quality improvement initiative, is one way to accomplish these results.

Why Lean Six Sigma versus Six Sigma:  Six Sigma approaches focus on statistical analysis to reduce errors, thus are quite prevalent in manufacturing industries.  Lean Six Sigma focuses on process evaluation to reduce waste and has spread from industry to industry after initial adaptation from Toyota Production Systems.  According to the Institute of Medicine, 30 to 40 cents of every dollar spent on healthcare is for costs associated with waste such as overuse, misuse, underuse, duplication, unnecessary repetition, system failure, inefficiency, and poor communication. 

While a focus on reducing errors is important, most organizations don’t have reliable, consistent data to pursue the rigor of statistical analysis required of Six Sigma.  Fortunately, given the rigor and concordance of triage decision support tools, the call center is not a common practice area prone to errors.  Thus, the application of Lean Six Sigma strategies to reduce waste makes more sense.

Others believe that the proportion of waste in healthcare can be estimated anywhere from between 30 to 60 percent, with only 10 percent of work performed being considered as value-added.  These are disturbing facts, but consider some of the common issues of waste such as waiting, handoff breakdown, errors and mistakes, correcting, revising, inaccessible information (such as a patient EMR), lack of tools or equipment, limited resources, inflexible processes that limit opportunities to improvise, and unnecessary movements that take time. 

A prime example of waste is work-around, otherwise known as those additional tasks or steps that become imbedded into processes during times of crisis or demand to meet a short-term need.  Many times these are put in place by well-meaning individuals, but work-arounds unfortunately get ingrained as “policy” through future on the job training and orientation – and are never revisited. 

Webster’s Dictionary defines value-added as “of, relating to, or being a product whose value has been increased especially by special manufacturing, marketing, or processing.”  Non-value-added tasks increase cost, time, and consume extra resources without directly delighting customers or callers.  Focusing on these types of additional activities is a gold mine for applying Lean thinking and strategies.

Strategies and Tools to Utilize: To stay competitive, healthcare call centers need to be able to provide consistently high quality services.  In essence, callers should expect uniformity in how their calls are handled, as well as the outcome or disposition regardless of shift, day, or agent.  Key elements include:

• Stabilization: remove excess variation in the call flow or call handling processes

• Standardize: establish work rules or procedures to outline best practice (charts or visual guides are usually helpful)

• Simplify: explore ways to keep it simple through work redistribution or technology

In order to achieve success, organizations must outline what teams will use as a standard improvement model.  A commonly used model is known as DMAIC (Define-Measure-Analyze-Improve-Control).  There are a number of resources available in the literature that outline different approaches DMAIC in Lean Six Sigma projects.  Organizations most commonly struggle with choosing appropriate tools to best help achieve success in accomplishing these steps.  The most commonly utilized tools include:

• Value stream mapping

• Non-value-added analysis

• Operational definitions

• Queuing theory

• Visual process control

A critical component for any Lean project is creating the infrastructure to champion and support the work teams.  It will not succeed if it becomes another “silo” in an organization.  Leadership most often makes decisions around infrastructure design to develop the business case, establish goals and budgets, and benchmark performance against other organizations if data is available.  The team members typically include managers, white or green belts, sponsors, champions, and for larger institutions, access to black belts.  The key factor is to be sure an include people from all aspects of the call handling process and those who have real work connections to how calls flow through the technology and phone switches.  These individuals involved in the front lines should have some initial training as either white or green belts. 

Leadership must then make it a priority to provide the time to review progress and hold line managers accountable for successfully engaging the work force.  As with any change, the mechanisms for communication (both up and down) become integral for any projects success.  This vital step ensures continued engagement and excitement for all involved.

Case Study from a Healthcare Call Center: Lean Six Sigma was applied in a rather large call center that employs over 300 nurses and processes greater than a million triage calls per year from multiple sites.  The organization had noticed that its call handling times were increasingly creeping up over the past few years, with no one indicator or reason identified as the cause.  Lackluster performance overall was jeopardizing client service levels resulting in financial penalties.  Next, the DMAIC model was applied:

• Define stage: The leadership team was noticing increasing complaints from callers about unnecessary questions being asked and re-asked.  In addition, the call handling metrics had increased from 10.5 minutes for a triage call up to 12-13 minutes.  RN turnover was another contributing factor to the call center's overall poor fiscal performance from quarter to quarter.  These were the three metrics chosen for the project.

• Measure phase: The organization brought in a consultant to provide an unbiased assessment in order to thoroughly understand the current state of call processing.  This was accomplished via observations at different times of day, involving multiple nurses and agents.  The organization had already collected data on team member satisfaction, quality audits, and productivity trending. 

• Analyze: A number of areas were identified during the intake and triage processing steps as non-value-added. 

o    Agents were manually logging all calls on intake and then entering them in to the system in case “the system went down” (a duplication of effort). 

o    Nurses asking irrelevant opening questions to assess for ABCs, regardless of the reason for the call (a source of frustration to nurses and callers).

o    Inadequate queue management strategies were being utilized. 

o    Various call process “rules,” developed over time, led to punitive auditing practices, eliminating critical thinking skills (leading to fear and frustration). 

• Improve: With key stakeholder input, the entire call handling process was retooled, focusing on minimizing non-value-added steps while ensuring there was no deviation from sound risk management practices.  Queue management was revitalized to ensure a “focus on the core” by assuring clinical oversight, prioritization, and realigning staffing patterns to cover peak call volumes.  The team was cognizant of inevitable “scope creep,” and this was mitigated through solid group facilitation techniques.

• Control: Initial results have yielded an impressive ROI based on decreasing call handle time by an average of 15 percent, improving service levels, and turnover of clinical staff down by 20 percent.  Validation of persistent improved performance will continue over the next six months to further quantify the financial results.  Plans are underway for celebrating the hard work and successful efforts.  Other opportunities identified during the process included exploring a remote workforce program, revamping the entire QI program from a focus of auditing to continuous improvement, and commitment to work with technology vendor to influence sustained input on enhancements. 

Presently, not much current literature exists relating to the success or failure of Lean Six Sigma strategies in healthcare call centers.  We need to encourage colleagues and call centers to share their experiences and celebrate their accomplishments to contribute to the overall success of health call centers during these troubled economic times.

Sherry Smith, RN, MSN, MBA, is a senior consultant for 3CN - Call Center Consulting Network, a network of health call center experts available to assist with strategic, operational, or technical projects.  Sherry can be contacted at 603-707-0151 or Sherry.smith@3cn.org.