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Jim Jordan:
Welcome to the Chalk Talk Jim Podcast, where we explore insights into healthcare that help uncover new opportunities for growth and success. I’m your host, Jim Jordan.
Jim Jordan:
Welcome to today’s podcast. And this week, we’re doing something a little different. We’re going to explore the principles of Lean and Six Sigma and how they can transform operations in hospitals, clinics, and doctors’ offices. In this two-part episode, I’m speaking to Al Da Silva, the founder and CEO of Business Consulting, which provides fractional chief operating officer services. Al has over ten years of healthcare experience. He has a BSN in nursing and a master’s in healthcare administration. He has major process initiatives that he’s done across hospitals and medical groups, and independent physician practices. And in part one today, we’ll be providing an overview of Lean and Six Sigma and looking for examples of their impact. So before we even go down, tell me a little bit more about yourself.
Al Da Silva:
Sounds good. So my name is Al Da Silva. I am a registered nurse and an entrepreneur. I have been a healthcare administrator both in the hospital side and the medical group side. And I got beaten by the entrepreneurship bug when somebody bought a car from somebody, asked me for help on the business plan, and it was not in healthcare. And then for the first time, after being in business for, I don’t know, 16, 18 years, I was able to bring together all of the knowledge and experience that I had and apply to an industry that I was not familiar and actually be able to put a, develop an idea into a product and then ready to go to market. And then being upset with the 9 to 5 world one day, I had been working and adding value, and somebody was trying to put a value on my time and what have you, and that same entrepreneur that I helped with the idea asked me this very question, he says, Al, why don’t you do this for yourself? And that, we were in, this is one sad thing about COVID is that it killed my favorite Cuban place in Memphis, Tennessee, and we were sitting there, this sounds almost comical and almost like a fairy tale story, but literally, this guy challenged me, and we picked up, I used to have one of those Lincoln’s notebooks, the little ones. I’d put it on my pocket. I took it out, and he started interviewing me, and I jot down a few ideas, and everything was a la carte. But then I shot this back to him, and I said this to him, James. I said, why in the world should I become a consultant? Everybody and their mother is a consultant, so why should I become a consultant? And then he challenged me. He said, if you’re going to do it, be different. Find something to challenge the status quo in consulting. And I said, well, I’ve got to think about that. So there it is, a little bit about who I am. And originally from Brazil, married to a beautiful wife, Sunshine is her name, and two beautiful kids, teenagers. And my wife is a registered nurse, so we live healthcare all the time.
Jim Jordan:
So what’s the name of your current organization?
Al Da Silva:
My organization is very, well you can say, James, original, Da Silva Consulting.
Jim Jordan:
There you go. And so, what services are you providing just so that our audience is clear on?
Al Da Silva:
Oh, absolutely, I end up developing a program called the Roadmap to Success to support small, mid-sized businesses with fractional chief operating officer program. And in that, we focus on four distinctive areas to bring value to those companies, and those areas is assessments, we help them understand where they are. So we developed a tool called the DSC Business X-ray assessment, we can talk more about that, James. The next piece is the understand where you want to be, and that’s our vision to bottom-line strategic plan, so we provide strategy, then not just drafting the strategy, understand how to get that strategy implemented. So we have developed a tactical plan that goes into 90-day spurts, and that’s our framework called the High-Performance Framework Tactical Plan. And, of course, every entrepreneur, no matter where you are or if you’re highly successful, you need guidance, you need a sounding board. And then, we have a program on the achieve, which is the virtual COO program, which is a more of a guidance program to the clients, and then we have a fractional COO program that’s a much deeper embedded leadership inside that company. So there, that’s our services.
Jim Jordan:
And what industries have you been serving?
Al Da Silva:
We’ve been mostly healthcare, James, but we’ve done projects. I’m very big and passionate about business literacy, James. I’ve been to business school. I cannot help, and I’m almost a geek out on this one, but I’ve been in business, to business school a couple of times. I went and got my MBA and then went and got my NHA. And what I have noticed being a geek and whatever you can name that, I don’t mind, but is, there are reasons why they teach you this stuff. And then, I started applying the stuff that I learned in business school in the real world, and I started getting positive results. So I give you an example. We’ve worked in healthcare, but I just gave you an example how we were able to help a banking organization. I gave you, we were have helped small manufacturers. We have helped large health systems, small medical group, large medical groups. We have helped construction companies. Right now, we are working with the hospice, just signed a hospice in healthcare to be their advisor as their virtual COO. So multiple industries, but our passion, myself being a critical care nurse, is healthcare.
Jim Jordan:
So let me ask, I’ll start out by sticking at the high level. Then, we’ll go down to the various healthcare folks that you work with. But when you take in non-healthcare customers, have you learned anything from them that you’ve brought to healthcare or the other way around? Is, has it been more that you’ve learned in healthcare that you’ve brought to them?
Al Da Silva:
Absolutely. I think the biggest thing that I see, James, is that everybody, no matter what the industry, is struggling with the same challenges. There’s opportunities to improve processes. There are certain industries that do a better job, for instance, banking, have a lot of processes that have been developed. And I think healthcare could learn a lot from banking, especially on the collaboration, how banking is able to collaborate. You can go all over the world, and you can stick your card in and get money out of it. It doesn’t matter what bank you’re from, but here’s what healthcare could work, could learn from banking, is that I could just go down the street and here in Memphis, Tennessee, and my doc cannot communicate with another doc because they don’t have a way to share that information in a very efficient way. Yeah, sure, you can send the printed chart, or you can send a file, but it’s not a seamless process. So I think healthcare could learn a lot from banking is just one industry that has figured out how to work together, leverage the data. Most importantly, people say this, James, Oh, the reason why we don’t do that is because it’s healthcare data. It has to be protected. But what about financial data? They figured out how to protect the financial data. Why can’t we figure out how to appropriately share medical records to impact patient care? And frankly, being in the US, you and I know that impacts the cost of delivering the care with how so many redundancies and waste. Talk about Lean, how much waste we have in just not being able to appropriately communicate with patients or appropriately understand their medical records to appropriately treat them and not have defensive medicine as one of the biggest challenges we have.
Jim Jordan:
Sure, now moving into the healthcare segment, what, you have hospices, you’ve worked with what other verticals in there have you worked with?
Al Da Silva:
You know, I’ve worked so, from the ground up, I give you my first job experience in healthcare. I understand a lot about lab operations. I was a phlebotomist, and I was able to fully understand lab operations from the ground up. I was a specimen processor. Eventually, I got involved in transforming lab operations using Lean and Six Sigma. I got exposed to seeing that first-hand. Then I became a nurse. And then, because of my first experience in manufacturing, I was in quality and operations. And that was the time that I got my MBA. And James, let me tell you, when I became a nurse, I was a weird nurse, okay? I had business training, but I was focused on really understanding how to take care of patients and seeing things from a, almost like a process engineer. How, I was like some of the processes just didn’t make sense, like, why is this stuff, why the most used supplies are not strategically placed in an area where decreases fatigue for a nurse? Those are some of the projects that I did, right? I would ask this question why can’t we decide on putting the glucose meters in a specific location where the nurse does not have to be looking for that? Look how many times the steps you’d be looking for things because somebody got it and then put it in the right place. So those are some of the things. I use that knowledge taking care of patients for seven years full time, and then I went into hospital operation where I got exposed to every single hospital department and running from surgery to lab, like I told you, radiology, pharmacy. I now manage pharmacies, and the reason why I have such an in-depth knowledge of pharmacy operations, James, is because, during my time at the hospital, I was able to do a Lean and Six Sigma project that transformed their pharmacy operations into from doing three hours of what, you fill one script and a new script should go in less than 23 minutes, to running enterprise-wide projects in helping health systems to decrease length of stay, those are some of the things, trauma registry work, helping them optimize the care for trauma patients, to then transition to large medical groups, academic medical groups, and working with surgeons and various other physicians on developing systems and processes. And I think the biggest thing that I learned in that time was how do you actually create a strategy at the physician level, James. And what I did there is most of the time, you will onboard a physician, you will learn a little bit about them, and it says, yeah, here, go be productive, and a lot of times, the support of that, those physicians was not there. They didn’t really, they were not really understood. So there was a lot of miscommunication between the administration. The set of expectations created a lot of friction. But when we develop a process to actually understand why that physician became a physician in the first place, and we understood his vision, his mission, what his values, what was some of the challenges, what he was trying to accomplish in the context of an academic world, then a lot of those physicians that were deemed unproductive became very productive and very successful.
Jim Jordan:
So at the risk, I was so excited to talk about Lean with you. I fear that we might risk having our own conversation and not keeping our audience updated as we go. So let me just pause for a second and talk about what I’m hearing, because I think it’s critical. I think there’s two things you point out that, when you look at healthcare and non-healthcare, there’s high-volume transactions that are predictable with security, safety, think about airplane tires, right? All sorts of things that have as many risks and requirements as healthcare does. I think that’s a fair learning for other industries. And so that makes you talk about the question, so why can’t we do that too? And then the other piece you’re sharing, which I think is intriguing to me, is you’ve basically covered all areas of healthcare. And I think as a former person who was a plant manager myself and made products in my day, I would step back and say the difference between, say, your lab operations and your hospital floor is that you have a fixed input, a fixed process, and a fixed output. And healthcare, by its very nature, is variable in terms of what’s coming in today, variable in a sense that based upon their variability, your protocol that you need to use could also shift, and therefore getting a fixed output is different, right? Fixed fixed fixed fixed versus variable fixed. But there are techniques out there, such as Lean and Six Sigma.
Al Da Silva:
That’s correct.
Jim Jordan:
That help you search out and remove what’s called non-value added. So in manufacturing terms, non-value added was, if you weren’t touching the product, you’re non-value added, that’s simple. And I guess in healthcare, we would say.
Al Da Silva:
The same thing.
Jim Jordan:
Nurses and physicians, everyone else is non-value added, right? Can you tell us, just for our audience educators, the difference between Lean and Six Sigma?
Al Da Silva:
Oh, absolutely.
Jim Jordan:
Yeah.
Al Da Silva:
So Lean focuses on the reduction of waste. So I gave you a quick example: motion. Like I gave you an example of the glucose meter inside a nursing unit. When that glucose meter does not make to a strategic location that decreases the amount of effort to actually find that machine to be able to do the test, then you are adding fatigue and frustration to your nurses, right? Also, the waste could be talent. So a lot of times, we hear people talking about, you got to work your professionals up to their license potential. So I’m going to give you an example. On the pharmacy that we transformed the operation, the pharmacies were doing clerk work. They were literally inputting the prescriptions themselves, but that could be the work of a technician, so we leverage the technicians. So that was waste, right? It was waste of the talent of that pharmacy. So that pharmacists went to school to be able to advise the patient, counsel the patient, understand the interactions of medications, and be able to then make safe disposition of those medications to those patients. So that’s an example of waste there. Six Sigma, to your point, James, is, it’s about consistency. It’s about taking the stakes out of the operation. Six Sigma is just a statistical process that accounts for 3.4 mistakes for 1 million opportunities. So it’s Six Sigma from the statistics standpoint, right? And most industries function in that 3 or 4. But let me give you some examples of some industries that function at a Six Sigma level. When was the last time that you were on a plane? That plane made it to point B, right? And planes don’t just fall off the skies every day. Nobody would be flying planes, and, you know, flying on planes. So that’s an industry that the requirement of performance is so high that mistakes are avoided. And the way that they do that is not because they’re better than healthcare, it’s because they have focused on putting systems, processes, checklists, to make sure that a plane, before it leaves the ground, is safe to fly. And that’s what we have to do in healthcare, like with processes, procedures, to avoid mistakes.
Jim Jordan:
So I was in a yard sale or a tag sale, as some people say, around the country, probably 25 years ago, and I found this management information book from like the 1950s for pennies on a dollar. And I read it, and it had one of the most formative ways of explaining the relationship between Lean and Sigma. And it was a computer scientist or a management information person basically saying that every process has error and planning flow deviations like something just went wrong. And at the end of the day, the process was designed with the natural variability. And so, I look at Lean as focusing on removing problems, flow planning issues, and the natural variability of a process is left. And Six Sigma goes in and says how can we make that variability be reduced I think is.
Al Da Silva:
That is correct. That’s beautifully said, James. That’s it. Like, when we manage our Six Sigma processes, we use control charts, and in that control chart, you have a medium or a mean, and then you have three standard deviations, right? So if you were to look at this, the middle line is your average. The top line is your upper control limit. Your bottom line is your lower control limit. So you can literally understand how much variation do you have in your processes, how many times your process actually falls outside those three standard deviations. And when we see that, James, in healthcare, I have processes that the variation was the norm. Are you talking about, like we’re talking about the emergency room patient, right? Best practice is 180 minutes. Some systems are dispositioning patients of low acuity in less than 90 minutes because they have created a process to decrease that variability between decision and disposition of those patients. But there are some systems, the variability is their process. And what happens there, James, is that says, no, every day is different, and it’s not true. They want to say it’s different, but it’s not. A cardiac patient is a cardiac patient. They come, they may have certain things happening to them, you have protocols that are done, and you need to maintain to where 80% of the patients that come, they go through your system in a very predictable pattern. And for those spaces that are very unusual, you have plans and mitigation that manages that variability in the process. And even those patients can get consistent care because you have a plan to manage those patients.
Jim Jordan:
So I imagine that training is a big part of what you’re doing when you go into these organizations, even when you come in is temporary leadership. I imagine that one of your personal missions, as they say, is to teach them to fish when you’re gone, right?
Al Da Silva:
That’s correct.
Jim Jordan:
What is your process, and how receptive are people in this industry to these techniques? Because this is a little new to them, right?
Al Da Silva:
It is and it is not, James, and here’s the thing. The biggest challenge with Six Sigma is that no Six Sigma project happens without a change management strategy, and that change management strategy has to happen at the top. No Six Sigma program is fully successful if it’s not coming from the executive team. It’s literally a commitment to this philosophy of no mistakes or no waste. And also, part of that is creating the just culture, and the just culture is the type of culture that you are implementing in your organization that allows your employees to give briefing back without fear of retaliation, or that they’re going to lose their jobs. And then when you create that culture of excellence, then you create the safe environment where people can start reporting mistakes and start reporting problems. And then with the support of the leaders and the support of middle management, you can then involve the bottom of your organization in fixing those problems. That’s what the power of Six Sigma comes, not a top-down approach, but it is a training like you mentioned, James, and the training and the mindset change of the bottom of your organization where they can become engaged. Now you have employees that are disengaged to becoming engaged in the process and fixing these clinical processes so they are safer for patients.
Jim Jordan:
So I think, do they, I believe they call that kaizen attitude, right? It continuous …
Al Da Silva:
Yeah.
Jim Jordan:
And I think part of the, part of that attitude, if I recall, is finding an error or a problem and calling it an opportunity as opposed to, and I think maybe in healthcare because we do, we deal with life and death and health and pain that probably, that’s a little bit of a harder culture to penetrate because error is not well tolerated, right?
Al Da Silva:
Absolutely, absolutely. Here’s the thing. You also have to speak the language of the healthcare profession, a lot of times. So what I’ve done with our philosophy, not only as an entire program or framework, James, is that we talk about terms that they can understand. So we talk to the doctor. Let’s assess this process, understand what some of the challenges that are happening here. Let’s diagnose some key areas of opportunities, to your point, you mentioned opportunity, not problem, this is an opportunity, right? After we understand what the problem is, we may run data, right? We want to quantify that. We want to do qualitative quantitative data. We then going to analyze that data, measure what the impact of that problem is, and now that we understand the problem we can then start talking about treating that process. So the same mindset or the same rationale that you used to treat a patient could be applied to fix a process. And then after you put the treatment plan in place, you can then talk about how we’re going to actually achieve the goals that were established regarding this opportunity. The opportunity may be reducing the time that patient spends in the emergency room, and it may be how long is it going to take between the time that patients sign up to the time the patient is to see the doctor, which is the value-added time like you’re talking about, non-value added. So if I am able to decrease all of the non-value added times between the patient showing up in the emergency room to the patient actually seeing the doctor and getting a decision, that’s the value. That’s why the patient showed up in the emergency room, right? You’re there to see the doctor, nobody else. The doctor is the value-added activity. And if we can shorten that time, provide that time, and then help the doctor with supporting processes, nurses, physical therapy, radiology, lab, you name it, to help that doctor make that decision to then send the patient home safely or admit the patient to the hospital, then we’ve done our job for that particular scenario.
Jim Jordan:
Thank you, Al. I think we’ll leave it here for today. That concludes part one of our conversation, where we talked about applying Lean and Six Sigma in healthcare. And in part two, we’re going to dive deeper into exactly how to implement improvements and make them sustainable. We’ll also discuss the importance of patient-focused design. Be sure to tune in when that episode is released. If you enjoyed this podcast, please leave us a review, and look forward to seeing you next time.
Jim Jordan:
Thanks for tuning in to the Chalk Talk Jim Podcast. For resources, show notes, and ways to get in touch, visit us at ChalkTalkJim.com.
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