The efficiency of general practice (GP) surgeries has long been in the public eye and  plans proposed by Lord Darzi, the health minister in 2008 aimed to amalgamate GP surgeries into large polyclinics, each offering services to around 50,000 patients.

The new structure proposed by Lord Darzi  meant huge changes in how the UK’s healthcare services operate, with efficiency as the main driver. At the same time as this new proposal, there were other recent changes to general practice, with the introduction of a new contract for paying general practitioners (GPs) and regularly changing criteria for how a surgery is run. South Street Surgery in Bishop’s Stortford, Hertfordshire is larger than average, with 20,000 patients opposed to a typical GP surgery which offers services to around 5,000 to 6,000 patients. Milinda Tennekoon is a GP principal at the surgery. He was well aware of the continuous changes and what they might have meant for his surgery. We have re-visited an article written and published originally in the BQF Excellence magazine. Here, Milinda explains why Lean Six Sigma in Healthcare works.

He says: ‘There has been quite a lot of change in service provision dictated from above, changing what we as a general practice have to achieve. We’ve had to realign our services to meet these changes; our funding is now associated with delivering services and if we don’t manage this our funding is reduced.’ A quality and outcomes framework has been introduced to GP practices, which takes into account different clinical and management areas and allocates points relating to the level of attainment achieved within each criteria. ‘The more you attain, the more points you are awarded and at the end of the day “points means prizes,”’ Milinda explains. ‘The thrust of this is to make funding more results orientated, rather than just activity based. We have been able to use this extra funding to improve even further the monitoring and treatment of many of our patients with chronic diseases, there by improving their overall health now and into the future. So basically it’s a good thing, a move to measuring the health service in a better way.

Improving services

As well as changes to funding, GP surgeries have been given additional resources in order to improve the services that they provide. South Street Surgery chose to invest these resources in a sustainable approach to manage the continuing change. The practice feels that industry changes, such as the increase in private providers entering the healthcare market, make it essential to embrace the changes and use the new opportunities to the greatest effect. ‘Traditionally,’ says Milinda, ‘GPs carry out the clinical work and run the business on the side, but we decided that in order to embrace new opportunities, such as funding, we needed to change our mindset and become more professional about the way we run the surgery.’

The structure of the surgery revolves around 14 GPs (including nine partners), nine nurses, and a large reception and administrative team. The practice operates from two different locations due to its large size. With the size of South Street Surgery in Bishop’s Stortford is the first GP surgery to introduce six sigma and achieve the BQF Committed to Excellence Award. Milinda Tennekoon, GP principal at the surgery, explains why the surgery effective communication within the practice has always been an issue, and this was highlighted in our initial assessment. With changes in practice managers and other members of the team over the last few years, the ease with which services can be managed has become more difficult.

In an attempt to improve leadership and business practices, the surgery decided to adopt a more process-based management structure, to involve all partners and staff in different parts of managing and developing the practice. However, it was quickly identified that this wasn’t a GP’s area of expertise, so the decision was made to bring in a consultant to structure thinking and carry out an organisational audit to uncover the various problems affecting the efficiency of the surgery.

Through a simple approach to organisational development – assess, improve and maintain (AIM) – several key problems became apparent in the initial assessment stage. Although some problems had already been realised, various things showed up that might never have appeared without a systematic audit. This provided the necessary shake-up and six sigma was identified as a process which could make changes to the system that the whole practice could work with. ‘We knew something wasn’t working,’ reflects Milinda, ‘but not the extent of it.

After the organisational audit we moved on to developing leadership skills and identifying our own team roles. As this started to fit in with where we wanted to go, we thought, lets see how it fits into six sigma.’ After the assessment stage had taken place and a business excellence manager was appointed, the key areas for development were prioritised. A combination of different lean and six sigma improvement tools were implemented, with the aim of identifying the root causes of the problems, mapping processes, identifying the value steps and rethinking the surgery’s processes using the data collected.

The challenges

There is a growing concern in the UK that more and more patients are going straight to the accident and emergency department at their local hospitals, rather than visiting their GP. The result of this could be that the NHS is charged twice for the visit. GPs are already paid via their salary to care for patients, but if the patient goes to a hospital, the hospital will claim that visit back from the NHS. Therefore, appointment availability is high on the government agenda. According to a government objective, practices are obliged to offer same-day appointments, making it possible to ring in the morning and receive an appointment for that day, and improving people’s ability to manage their working life.

At South Street Surgery, there are about 160 separate appointments a day, with additional nursing appointments, so making sure these are easily available is a top priority. The issue was initially tackled by measuring and monitoring the problem using various six sigma tools and techniques. Milinda describes the methodology: ‘Before we started to apply a response to the problem, such as to change the call system, we decided to take a step back and look at the call data we had collected. We measured the time that it took for patients to get through to reception, for example how long they had to wait in line. From this we could establish at what time the highest volume of calls come through to reception staff.’

After monitoring the call data, it became apparent that the major peak in calls occurred first thing in the morning, when the surgery opens its doors at 8.30am. This led to an examination into why the phones were not satisfactorily answered at this time of day and investigating the key six sigma question, ‘how does the work get done?’ ‘Through this process,’ Milinda says, ‘we identified that the peak corresponded to the time of day when the fewest staff were available to answer the phones – a simple answer in retrospect. It was collectively decided that a team approach was needed to tackle the problem and we managed to agree with various staff that teams would help to answer the phones.’

The team used a key six sigma concept to address this issue – by involving the whole team, problems can be solved. In the approach the surgery has decided to adopt, using a mixture of six sigma and kaizen, it is considered essential that employees from all levels of the organisation feel able to improve the processes of the way they work. All members of the team were consulted at the surgery and they all stepped in to solve the problem.

A second key challenge became apparent during the investigation, which wasn’t so easy to measure. With such a large number of doctors operating in the surgery, continuity became a issue. A patient would see one doctor about a problem and then be unable to make an appointment with the same doctor, leading both to dissatisfaction on the patient’s part and duplication in paperwork in the surgery.

To solve the problem, the surgery decided to tackle the way results were given back to patients by adopting a new system. It was agreed that once a doctor found something abnormal in a patient’s results, the patient would be called and an appointment made to see that specific doctor. To this end, time slots were allocated in GPs’ surgery time to make calls, which were then recorded by having the GP’s name written against the patient on the list so a log could be kept about who had called who. However, when the topic was reviewed, according to the six sigma method of continuous improvement, it seemed that people weren’t always entering their names when a patient had been called. As Milinda says, ‘We’re now at the stage of going back to see how we can improve that system and improve continuity.’

What next?

The surgery began its Six Sigma initiative in 2008 and it is an ongoing journey.

Milinda explained: ‘One of the issues that we have identified is that because there are so many things to do and problems to tackle, it’s hard to see what needs to be done. Allocating the time and importance to different areas is quite difficult. The challenge is in knowing what to prioritise, which is hard to realise as we still have to work on our strategy. That’s the stage we’re at now; pinning down our strategy in terms of mileposts and direction, which will then allow us to streamline our efforts a bit more.’

Having appointed a business excellence manager, the surgery is now investing in training so that the manager can fully embrace her six sigma role. Other key individuals will also be trained in the future, so there are groups available for discussion and the surgery can continue to make positive changes to its structure.

Changes made as a result of using six sigma techniques have ensured a more streamlined operation. Milinda says: ‘Making changes has been difficult mainly because decision making wasn’t very efficient. For all partners to understand all the issues well enough in order to make a decision by consensus was very time consuming. We were getting bogged down. ‘Now, with our process architecture in place, decision making within our own areas will be much more efficient and wasted effort and resources can be reduced. One thing we noticed was our staff turnover rate was quite high.

Our initial assessment showed a degree of staff dissatisfaction, but our assessment this year has shown that staff satisfaction has been much better.’ Milinda has some advice for others considering six sigma: ‘To take on six sigma I’d say that you have to do everything in an organised way, right from the beginning. You can’t just take a little from here and there, which is why having a consultant has been very useful. It’s helped encourage us and keep us moving in the right direction. It also reassures us we are moving forward in a planned way, rather than just reacting to situations. ‘The feedback from the initial assessment was difficult to hear, but it gave us the drive to improve things, and by thinking creatively to tackle the problems.’

In the future, the main goal for Milinda is a happier surgery. ‘All doctors are caring and have good relationships with their patients, but there has been a lot of dissatisfaction with what we’re doing. With our new structure we hope to see a lot less stress and a better relationship with our patients and staff.’

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