Improving Process Performance
Task: Read the Case Study below and use the Lean Six Sigma DMAIC methodology and associated appropriate tools to select and solve a relevant problem situation.
Hospital Food Case Study
Introduction
Hospital food is an emotive subject and engenders headlines, usually negative, in the national newspapers. The NHS spends around £500 million on food to serve 300 million meals in 1,200 hospitals every year. For example, it buys 1.3 million chicken legs, 12.3 million loaves of bread, 13.5 million kgs of potatoes and 250,000 litres of orange juice a year. In 2000, a newspaper article estimated hospital food wastage at £144 million per year – almost three times the Department of Health estimate of £45 million. One of the main reasons being cited for the wastage was the poor quality of the food, although a definition of quality was not offered. Hospitals can deliver their catering services in-house; however, the NHS tendering process allows hospital trusts to outsource their catering processes if they want. Experts in food nutrition are concerned about the low priority given to the nutritional value of the food, with many patients becoming undernourished during their stay in hospital. Food is viewed by medical staff as part of the recovery process.

With regards to food quality hospitals do survey patients’ attitudes to the meals provided, some hold focus groups and generally ask about overall quality, temperature and how they were served at the bedside. Most patients have low expectations but meals are often the highlight of the day, especially for long stay patients.

Food Services
Over the years, the need to improve efficiency has resulted in reductions in staff numbers involved in the hospital catering service, along with centralisation of skills and equipment to produce economies of scale.
There are now many possible variations in food service and either an in-house operator or a contract operator could manage the food service.
The following are simplified overviews of the different systems (although every hospital can have a different variation according to local circumstances):

(a) The food can be produced on-site using a cook-serve system

A cook-serve system is a “traditional” catering operation where food is prepared on-site and distributed at the appropriate temperature to the wards, either plated or in bulk. This system allows for batch cooking which minimises hot-holding and nutrient losses and optimises the food’s sensory characteristics as it can be prepared close to the time required. However, in practice there can be a substantial time delay between production and consumption as wards are often situated a long way from the kitchens. The result is that many of the potential advantages are not realised. It is important that the food is served at 63ºC or above to control the multiplication of bacteria in the food.

Figure 1: A Simplified Traditional System

(b) The food can be produced off-site by a cook-chill or cook-freeze manufacturer (total delivered meals)
In this system, production of meals is separate from the service of those meals, thus there is a decoupling of service from production. The hospitals receive a plated service where food is delivered to the hospital kitchen for re-heating before being served.

Figure 2: A Simplified Delivered Meals System

Riverside Hospital
The hospital in this case study is one of the five core hospitals situated in the Merseyside region of the North West of England. It is a relatively large hospital delivering general hospital services to a population of around 100,000 making it a very fast paced organisation. The hospital consists of over 900 beds across the 30 wards and private rooms, treating an estimated 2000 patients a day including out-patients. The hospital employs over 2,000 employees on a full and part time basis, but also outsources many of its duties to nearby companies, e.g. cleaning and catering. The catering at the hospital is outsourced to a food manufacturing company situated approximately 20 miles away from the hospital. The cost of feeding a patient is £3 per day.

(a) Food Ordering System
When a patient is admitted to Riverside hospital and assigned a ward their nutritional needs are assessed by the nursing staff and a dietician. Menus must be nutritionally acceptable and within current cost controls. Patients get three meals per day – breakfast at around 8am, lunch at around 1pm and dinner at around 6pm. They are then given a Menu card from which to select their meals for the next day – breakfast, lunch and dinner (See appendix 5 for sample menu). Menu cards are normally distributed and collected from patients in the evening. The completed menu cards are sent to the hospital caterers who pass on the orders to the food manufacturers who produce the meals.
Problems occur when a patient arrives in the morning and is assigned the bed of a recently discharged patient. The meal or meals they receive that day was ordered the previous evening by the discharged patient.

(b) Food Delivery Process
The manufacturing company cooks and chills the food before plating and loading on trolleys prior to transportation to the hospital. At the hospital the food trolleys are taken by porters from the delivery van to the kitchen where they are then reheated in a trolley known as the ‘Reheating Unit’. The Standard Operating Procedure states that the food must be reheated for 40 minutes. The heated food is then taken on trolleys down a corridor to a lift. Once on the lift the food travels up 4 floors to the ward. On exiting the lift, the trolleys are pushed down another corridor to the entrance of the ward. The nurse on duty then checks the delivery against what was ordered before distributing the meals to patients. The hospital receives roughly around 2,500 meals per day from the factory and distributes the meals around the wards.

(c) Issues
The hospital has received 375 complaints in the last year regarding the quality of their patients’ meals, which is a real cause of concern, particularly given that an increasing number of patients are leaving their care malnourished and the amount of food waste is increasing. The latter has led the hospital and indeed the NHS to consider possible alternatives to improving the delivery of meals from kitchen to patient. Previous initiatives had already led to a spend of over £50 million for the NHS, for example, the design of new menus by top chefs and the Lloyd Grossman initiatives for Better Hospital Food. For every 30 meals delivered the equivalent of 6 meals is wasted in the case study hospital. It has now realised that it is vital to find a solution for this well known problem and it is a corporate goal to reduce or eliminate food waste as far as possible.

(d) Management Actions
In order to gauge the extent of the problem Riverside Hospital conducted a patient satisfaction survey (See Appendix 1) and carried out a cost comparison of the average cost of feeding a patient per day and a food wastage Benchmarking Exercise with 4 other Hospitals in the same Region (See Appendix 3);

The hospital also decided to measure various stages of its food delivery system from manufacturer to patient (See Appendix 2) to see if it could identify any problem areas;
Patient Focus Group research found that the reasons for the non-eating of meals by patients were:
• Food not the correct temperature, e.g. cold soup, warm milk;
• Not the meal ordered;
• Cultural or personal food preferences ignored, e.g. halal or vegetarian;
• Poor quality meal ingredients;
• Poor quality cooking (over or under cooked);
• Patient not hungry (may be recovering from surgery etc);
• Portion size too large;
• Patient required assistance that was not available.

The management team also decided to collect data on food temperature as it arrived at the wards and to measure the time taken to deliver the meals to the wards (See appendix 4).

Having undertaken these various surveys and measures the Hospital Management Team were at a loss to know what to do with the data and were puzzled as to how that data could be used to identify solutions to their “food problem”.

Assignment Task
You are a Lean Six Sigma Green Belt assigned to address the Riverside Hospital food problems. Apply the Lean Six Sigma DMAIC Methodology to the Riverside Case Study and write a report detailing each stage of the project you select for improvement.

In particular you should:
Define the problem:

• Select a suitable project for improvement;
• Make a business case for your selected project;
• Write a project problem statement;
• Write an objective statement(s);
• Draw a SIPOC map;
• Conduct a Pareto analysis
• Apply Y = F (X) + E to your problem (identify your desired output and independent variables).
• Identify variables that are Critical to quality for the patient;
• Identify variables that are Critical to quality for the caterers.

Measure:
• Map the value stream for your selected problem;
• Build a House of Quality
• Calculate the food delivery cycle time;
• Calculate DPMO and hence Sigma level for the hospital meals process;
• Draw appropriate run charts and / or process control charts;

Analyse:
• Identify value and non-value added process steps;
• Draw a cause and effect diagram to identify potential causes to your problem.
• Use Why-Why and How-How analysis;
• Using appropriate data construct a Scatter Diagram and investigate any possible correlations;

Improve:
• Redraw the improved value-stream for the food delivery process;
• Calculate the new cycle time and savings;
• Suggest further improvements to the processes that could help improve the problem situation even more.

Control:
• Identify measures that you can take to ensure that the potential improvements recognised are achieved in reality and those improvements maintained.

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