The tension in the support services division between biomeds and mechanics at the University of Colorado Hospital, Aurora, was so thick on some days you could cut it with the proverbial knife. The problem? A large, open shared space that housed all their equipment as well as their work spaces. They often bumped into one another in the course of doing their jobs and had to climb over one another’s equipment. Mechanics welded next to technicians fixing sensitive ultrasound and dialysis systems, and an array of high-tech machines and tools lay around the large room in a haphazard fashion. In the middle of it all sat a huge table that the mechanics used to occasionally fix things and as a lunch table. It was constantly in the way.

“We wanted to move it,” says Fred Jaramillo, biomed contract manager for the hospital. “But the mechanics got very upset. It was, ‘What? You’re taking away our break table? Why are you doing this to us?’ It became obvious the situation was highly disruptive. We had to find a way to resolve the problem as quickly as possible.”

Knowing that it would require both a technical solution and—equally important—buy-in from both sides on any changes, Jaramillo employed a process first developed by Motorola in 1986 called Six Sigma, a business strategy using a set of quality management methods to reduce product defects. Utilized today by a number of large corporations, it is based on the belief that a company can achieve greater efficiency by continuous efforts of measuring, analyzing, and improving manufacturing and business practices, coupled with complete employee buy-in. The method is based on the idea that the maturity of a manufacturing process can be described by a sigma rating, which is its percentage of defect-free products. A six-sigma rating is given to a process that yields a 99.99966% defect-free result.

It is not without its detractors, including some who follow the concepts of another quality management methodology called Lean production—or Lean manufacturing. In many ways, these two—Six Sigma and Lean, as it is most often called—are the two current titans of corporate efficiency models. Which one is better depends on whom you ask.

Six Sigma in Action

Jaramillo, who had been exposed to the process a few years before, chose Six Sigma. With the help of a manager in the hospital’s human resources department who also knew the process, he went to work.

“We applied the Six Sigma principles by measuring everything, including floor space, chairs, tables, desks, and cabinets,” Jaramillo says. “We categorized and measured all the equipment and developed workflow charts. By then, the mechanics saw what we were doing and got interested, and pretty soon we were working closely together. We picked ‘champions’ from both sides who worked together, and they even went on a field trip to see how other companies had resolved similar problems. In a relatively short period of time, we reorganized the entire work space, built storage areas for the equipment, and resolved the ‘table problem.’ ” They solved that problem by attaching wheels to the table so it could roll into the open space for lunch and off to the side the rest of the day.

“Fixing the technical issues was important, but the key thing was we got buy-in from everyone,” Jaramillo says. “We wanted everyone to be able to give suggestions and participate. We haven’t yet figured out how much we have saved in terms of dollars, but there is no question that our workflow process is far more efficient than before.”

Getting Lean

Both Lean and Six Sigma reach for the same end goal of making a company or department more efficient—a goal achieved through strong leadership and support,and with employee buy-in.

Simplified, Six Sigma focuses on minimizing defects by measuring, analyzing, and improving the work process, while the Lean concept centers on eliminating all nonessential work and provides a methodology for identifying and cutting waste. In general terms, Lean production methods are aimed at achieving the smoothest possible delivery flow of value to customers. Ben Franklin was one of the first to publicly contribute to early Lean thinking when he wrote in Poor Richard’s Almanac, “He that idly loses 5 times worth of time, loses 5 times, and might as prudently have thrown 5 times into the river.”

The concept lies at the base of a complex change blueprint developed by Toyota in post-War Japan called the Toyota production system (TPS). It targeted waste, and the TPS ultimately contained a number of intricate ways to reduce and eliminate it. The process eventually spilled out of Toyota’s hands and has now become a staple in many companies. A number of health organizations use Lean, including the Oregon Health & Science University, Portland.

“We’re currently in a 25% growth pattern, and our hospital has a 95% occupancy rate,” says Peter Hazel, director of patient care finance and operation at the hospital. “The Lean process certainly helped us achieve those numbers.”

The hospital evaluated historical workflow methods, including how technologists worked with equipment and customers, and it eliminated all nonvalue-added tasks, according to Dennis Minsent, MSBE, CCE, CBET, director, clinical technology services, Oregon Health & Science University, who worked with Hazel. Utilizing value-stream mapping and other methods, the Lean team focused first on identifying wasteful practices.

“An example was our long-established maintenance inspections,” Minsent says. “Although we’ve always done them, we found they had no real impact. We replaced them with a process that included the biomeds taking notes during their regular rounds through the nurse’s unit. They talked to nurses and patients directly, asking about their needs—were there issues with the beds, TVs, drippy faucets, flickering lights, or were the nurse call sounds audible?”

The process not only proved more efficient, it made the nurses and patients feel their needs were being addressed. With 95% occupancy, it is urgent that the hospital “Lean-out” its operation. “We have to take out all waste, especially in areas that might be extending the length of patient stay,” Hazel says. “For example, are there any unnecessary steps in filling out prescriptions or processing discharge paperwork? We want patients to stay as long as they need to, but we also have to be as efficient as possible so new patients have a bed when they need one. Lean has been great in managing patient flow.”

“I learned the Lean process about 5 years ago at an AAMI [Association for the Advancement of Medical Instrumentation] conference,” Minsent says. “It just made sense to me.”

Hazel trained in the Lean process at the University of Michigan last fall. “I drank the Kool-Aid, and I went to work with Dennis, who had also drunk the Kool-Aid and we started moving fast,” he says.

Improving Workflow

The end goal of Lean and Six Sigma are essentially the same: to make the company more efficient. However, while Hazel and Minsent focused on eliminating wasteful processes, Six Sigma advocates, including Izabella Gieras, the director of clinical technology at the Huntington Memorial Hospital in Pasadena, Calif, concentrate on scientific and mathematical measurement, analysis, and improvement of work processes.

Gieras, a Six Sigma advocate since 2005, recently launched an ambitious new project based on Six Sigma concepts to help sort out the in- and outgoing flow of equipment in her department. When Gieras took over the department in August 2010, she found that some of the equipment, which included defibrillators, infusion and feeding pumps, patient monitors, and other devices, needed more coordinated priority arrangements. “It was critical that we develop a process to reduce turnaround time,” Gieras says.

She and her team quickly built new methods for collecting, storing, and inspecting the incoming medical systems. “We had equipment piled in different areas of the department and the storage areas, so we put together a flow process, which helped establish new ways to label and effectively store each piece,” she says. “We are also enhancing our current process for inspecting each piece as it comes in, making sure it has user manuals and purchase order information, and that it works properly.”

The department continues to perfect the procedure to ensure a faster and more efficient routing of the devices. “There are times when we have to decide which piece of equipment should be processed first because some equipment involves life support,” Gieras says. “Now, each piece is processed from point A to point Z quickly and efficiently, and none of it is falling into ‘black holes’ anymore.”

The benefits of the new practice could be substantial. The time savings that may result could allow the department to expand its services to include courtesy calls to end users to let them know the device is ready, or possibly taking the tools to the customers. Employees could also use the time to offer in-service or coordinated training on a system with the vendor, as well as other projects. Enhancing the current method will also help Gieras and her department make better assessments on warranties and what type of devices are needed, as well as how much it will cost to maintain them.

Since the procedure is new and is still being improved, Gieras says that it is too early for quantitative time or financial savings measurements. However, she expresses optimism that it will yield a variety of benefits in the future.

Unified Support

An important similarity in all three of these departments, regardless of whether they use Six Sigma or Lean, is that the biggest challenge is getting buy-in from employees.

“We started with two groups in an adversarial relationship,” Jaramillo says. “The biggest thing we had to do was get everybody involved so they all felt they had a say in the changes that were made. We went to every employee and asked them to list only the equipment they really needed. You wouldn’t believe how much garbage came out of that room and how clean it looked when we were done.”

Jaramillo employed an outside mediator to help smooth the process and wrote stories chronicling the progress of the project in the company’s employee newsletter.

In addition to making their lists, they also set up a system of weekly meetings. “Everyone could make suggestions on how to make the workspace and processes more efficient,” Jaramillo says. “We weren’t sure how everyone would react at first, but as soon as they realized these changes were really working, everyone chipped in and a real cooperative spirit began to grow.”

Have you or your hospital used Six Sigma or Lean processes? Blog about it with us at The Biomeds’ Blog.

In her experience of studying and participating in this kind of change, Gieras found that leaders need patience concerning the speed of employee buy-in. Although it can come quickly in some sectors, most leaders find it often moves more slowly than they would like, especially if prior change efforts in the department either failed or were abandoned.

However, while overcoming employee skepticism can be difficult at times, it is critical. “In our case, our employees had to be convinced that this wasn’t just another exercise with no outcome,” Minsent says. “We had to show them we were serious and that the methodology benefited them personally.”

The department expedited the process to keep employees engaged, but getting people to move outside their comfort zones presented a challenge. It held regular meetings to elicit employee suggestions and to let staff know the changes they were making were vital to the success of the organization.

“One of the great things about the Lean process is that employees can see fairly quickly that identifying and eliminating wasteful processes sets them free to do much more important things,” Hazel says. “We also tell frequent success stories of what we’ve done before, and hold regular meetings. In our favor is the fact that people naturally like eliminating wasteful practices. We are hoping to bring Lean principles to our 12,000 employees. In today’s economy, increasing productivity without increasing staff is the only way many companies can survive.”

Michael Bowker is a contributing writer for 24×7. For more information, contact