Healthcaresixsigmacases.doc

Healthcaresixsigmacases

Title: Who moved my sigma... Effective implementation of the Six Sigma methodology to hospitals Author(s): Frings GW, Grant L Source: QUALITY AND RELIABILITY ENGINEERING INTERNATIONAL 21 (3): 311-328 APR 2005 Document Type: Article Language: English

Cited References: 13       Times Cited: 1         Abstract: Six Sigma breakthrough strategy emphasizes the importance of reducing cycle time and improving customer satisfaction in determining optimal levels and costs of service quality. The implementation of Six Sigma to service industries is relatively new in comparison with the application of Six Sigma to industrial processes. In this paper, we consider aspects of the first three steps of the Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) initiative and postulate the potential for effectiveness of Six Sigma methodology implementation to the following hospital processes: Operating Room preparation upon surgical cancellation or rescheduling, Health Insurance Portability and Accountability Act compliance, Orthopaedic Joint Replacement Programs, and Patient Discharge processes. What is referred to as necessary 'critical-to-quality' (CTQ) aspects of medical services are not entirely different from the manufacturing environment. Developing measures of medical service processes from a 'unit of product' point of view raises new insights into the medical services field. Through investigation we find relationships between Six Sigma implementation and the potential for improved efficiency and effectiveness of hospital medical services. The results have implications for increased application of Six Sigma to hospital processes in those service areas. Copyright (c) 2005 John Wiley S Sons, Ltd. Author Keywords: Six Sigma; efficiency in healthcare; quality programs in healthcare industry Addresses: Frings GW (reprint author), Univ Richmond, Management Inst, Richmond, VA 23173 USAUniv Richmond, Management Inst, Richmond, VA 23173 USA E-mail Addresses: [email protected] Publisher: JOHN WILEY & SONS LTD, THE ATRIUM, SOUTHERN GATE, CHICHESTER PO19 8SQ, W SUSSEX, ENGLAND Subject Category: ENGINEERING, MULTIDISCIPLINARY; OPERATIONS RESEARCH & MANAGEMENT SCIENCE IDS Number: 911SC ISSN: 0748-8017

Title: Leading business improvement: a new role for statisticians and quality professionals Author(s): Snee RD

Source: QUALITY AND RELIABILITY ENGINEERING INTERNATIONAL 21 (3): 235-242 APR 2005 Document Type: Article Language: English

Cited References: 15       Times Cited: 0        Abstract: Following the successes of Motorola, Allied-Signal, General Electric and others, many companies are implementing the Six Sigma approach to business improvement. Millions of dollars are being saved in the process. Active leadership by management and others involved is integral to the method and critical to its success. This development provides a unique opportunity for statisticians and quality professionals to be leaders in their organizations. The leadership roles are discussed and it is shown how statisticians and quality professionals can assume leadership roles throughout the deployment process. As a result statisticians and quality professionals can expand their roles as internal trainers and consultants to include being leaders of business improvement. In the process their focus moves from facilitation of technical applications to the implementation of Six Sigma, skill deployment and delivery of bottom line business results. Copyright (c) 2005 John Wiley F Sons, Ltd. Author Keywords: improvement; leadership; process; quality professionals; Six Sigma; statisticians KeyWords Plus: 6 SIGMA; FUTURE Addresses: Snee RD (reprint author), Tunnell Consulting, Performance Excellence, King Of Prussia, PA USATunnell Consulting, Performance Excellence, King Of Prussia, PA USA E-mail Addresses: [email protected] Publisher: JOHN WILEY & SONS LTD, THE ATRIUM, SOUTHERN GATE, CHICHESTER PO19 8SQ, W SUSSEX, ENGLAND Subject Category: ENGINEERING, MULTIDISCIPLINARY; OPERATIONS RESEARCH & MANAGEMENT SCIENCE IDS Number: 911SC ISSN: 0748-8017

Title: On the quest for six sigma Author(s): Moorman DW Source: AMERICAN JOURNAL OF SURGERY 189 (3): 253-258 MAR 2005 Document Type: Editorial Material Language: English

Cited References: 13       Times Cited: 2         Abstract: A review of patient safety from a surgical perspective with emphasis on erosion of hierarchy, human factors, and an institutional implementation of multidisciplinary team training to create highly effective dynamic teams. Suggestions include further opportunities to enhance patient safety in surgical patients. (c) 2005 Excerpta Medica Inc. All rights reserved. Author Keywords: patient safety; team training; quality; dynamic teams; patient care team KeyWords Plus: HOSPITALIZED-PATIENTS; ADVERSE EVENTS

Addresses: Moorman DW (reprint author), Harvard Univ, Sch Med, Dept Surg, Beth Israel Deaconess Med Ctr, 110 Francis St,Suite 3-A, Boston, MA 02215 USAHarvard Univ, Sch Med, Dept Surg, Beth Israel Deaconess Med Ctr, Boston, MA 02215 USA E-mail Addresses: [email protected] Publisher: EXCERPTA MEDICA INC, 650 AVENUE OF THE AMERICAS, NEW YORK, NY 10011 USA Subject Category: SURGERY IDS Number: 912NA ISSN: 0002-9610

Title: Is health care ready for six sigma quality? Author(s): Chassin MR Source: MILBANK QUARTERLY 76 (4): 565-+ 1998 Document Type: Article Language: English

Cited References: 61       Times Cited: 92         Abstract: Serious, widespread problems exist in the quality of U.S. health care: too many patients are exposed to the risks of unnecessary services; opportunities to use effective care are missed; and preventable errors lead to injuries. Advanced practitioners of industrial quality management, like Motorola and General Electric, have committed themselves to reducing the frequency of defects in their business processes to fewer than 3.4 per million, a strategy known as Six Sigma Quality. In health care, quality problems frequently occur at rates of 20 to 50 percent, or 200,000 to 500,000 per million. In order to approach Six Sigma levels of quality, the health care sector must address the underlying causes of error and make important changes: adopting new educational models; devising strategies to increase consumer awareness; and encouraging public and private investment in quality improvement. KeyWords Plus: NEW-YORK-STATE; FEE-FOR-SERVICE; MEDICAL OUTCOMES; ADVERSE EVENTS; HOSPITALIZED-PATIENTS; AMBULATORY CARE; MORTALITY; PHYSICIANS; INSURANCE; VOLUME Addresses: Chassin MR (reprint author), Mt Sinai Med Ctr, Dept Hlth Policy, 1 Gustave L Levy Pl,Box 1077, New York, NY 10029 USAMt Sinai Sch Med, New York, NY USA E-mail Addresses: [email protected] Publisher: BLACKWELL PUBLISHERS, 350 MAIN STREET, STE 6, MALDEN, MA 02148 USA Subject Category: HEALTH CARE SCIENCES & SERVICES; HEALTH POLICY & SERVICES IDS Number: 150FR ISSN: 0887-378X

Editorial

Robin Gourlay. International Journal of Health Care Quality Assurance . Bradford: 2005.Vol.18, Iss. 4/5;  pg. 331, 2 pgs

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Subjects: Health care industry,  Total quality ,  Models

Classification Codes 9175   Western Europe ,  8320   Health care industry ,  5320   Quality control

Locations: United Kingdom--UK

Author(s): Robin Gourlay

Document types: Editorial

Publication title: International Journal of Health Care Quality Assurance . Bradford: 2005. Vol. 18, Iss.

Source type: Periodical

ISSN/ISBN: 09526862

ProQuest document ID: 915116531

Text Word Count 833

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Abstract (Document Summary)

Many health care institutions subscribe to the quality development approach based on "continuous" quality improvement (CQI). CQI, it is said, is an ongoing process whereby top management takes whatever steps are necessary to enable everyone in the organization in the course of performing their duties to establish and achieve standards which meet or exceed the needs and expectations of their customers both internal and external. Researchers explored a model of CQI implementation developed by O'Brien et al. The model identified four key dimensions for successful implementation of CQI namely: cultural dimension, technical dimension, strategic dimension and structure dimension. The four dimensions model is a useful way of building up a check list of questions to test whether progress is being made and what impediments are being encountered in the implementation of CQI. The dimensions cover significant issues which will be illuminated as the hospital makes progress and moves towards a successful implementation of CQI.

Six Sigma: Adapting GE's lessons to health care

Walter H Ettinger. Trustee. Chicago: Sep 2001.Vol.54, Iss. 8;  pg. 10, 5 pgs

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Subjects: Hospital systems ,  Case studies,  Corporate culture,  Strategic planningadvantage,  Quality of service

Classification Codes 9190   United States ,  8320   Health care industry ,  9110   Company specific ,  2200   Managerial skills,  2310   Planning ,  5320   Quality control

Locations: United States,  US

Companies: Virtua Health (NAICS: 622110 )

Author(s): Walter H Ettinger

Document types: Cover Story

Publication title: Trustee. Chicago: Sep 2001. Vol. 54, Iss. 8;  pg. 10, 5 pgs

Source type: Periodical

ISSN/ISBN: 00413674

ProQuest document ID: 80845500

Text Word Count 3048

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Abstract (Document Summary)

All health care stakeholders want to find ways to make their organization perform better. Increasingly, health care leaders have also realized that they must reevaluate their institution's culture, along with their overall management strategies, to maintain a competitive edge and keep pace with an evolving industry. Having tried and failed to find the holy grail within their own industry, providers are now looking beyond the health care field to other industries for best practices in managing both cost and quality. Arguably among the most successful approaches in any industry has been the General Electric Co.'s application of Six Sigma, with its related management technologies. Translating the Six Sigma method to healthcare has been key to the success of ongoing quality and culture changes at Virtua Health in New Jersey. Through Six Sigma, Virtua sought to fundamentally change it management and operating culture and become even more competitive in its market.

Full Text (3048   words)

Copyright American Hospital Publishing, Inc. Sep 2001

[Headnote]HOW VITURA HEALTH APPLIED A QUALITY TECHNIQUE FROM MANUFACTURING

All health care stakeholders, from the board on down, want to find ways to make their organizations perform better. Increasingly, health care leaders have also realized they must reevaluate their institution's culture, along with their overall management strategies, to maintain a competitive edge and keep pace with an evolving industry. They're recognizing that managers must be encouraged to move beyond accountability for simple technical knowledge of specific functions, and seek a results-focused, interdepartmental way to target the root causes of quality and efficiency problems. Having tried and failed to find the holy trail within their own industry, providers are now looking beyond the health care field to other industries for best practices in managing both cost and quality. The transportation, retailing, hospitality, and manufacturing industries, among others, offer valuable case studies for change. Arguably among the most successful approaches in any industry has been the General Electric Company's application of Six Sigma, with its related management methodologies.

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Sigma Levels

Achieving high levels of quality, productivity, and financial resilience has been an evolutionary process at GE. Understanding that yesterday's top-down management approach would not work in a new, fast-paced environment of technological change and international competition, CEO Jack Welch set out to lead a series of initiatives to make GE a more agile and dynamic organization. For the last five years, GE has led an aggressive campaign to cultivate the use of the Six Sigma quality improvement process throughout the company. The results have been impressive: over $3 billion in savings and a 20 percent gain in productivity. It has been so successful, in fact, that GE's customers, including health care providers, have asked the company to help them adapt

Six Sigma to their own organizations.

Translating the Six Sigma method to health care has been key to the success of an ongoing quality and culture change at Virtua Health, a four-hospital system in New Jersey. Created in 1998 through the merger of West Jersey Health System and Memorial Health Alliance of Burlington County, Virtua has become the dominant provider in the New Jersey suburbs of Philadelphia, bringing together four hospitals, two ambulatory surgery centers, two long-term care facilities, a health fitness center, and a home health company. And although most indicators showed that the system was performing at an average level, the board and senior executive team decided this was not good enough.

Through Six Sigma, Virtua sought to fundamentally change its management and operating culture and become even more competitive in its market. But could a management approach developed by a large international manufacturing company be applied successfully to an integrated health system? Absolutely. Not only that, but the implementation of Six Sigma also provides a case study in how our health system is leveraging the enthusiasm and commitment of its trustees to obtain system-wide quality improvement. To understand how we used Six Sigma for our purposes though, we first need to explain what it is and how it works.

Six Sigma at a Glance

Sigma is the Greek letter assigned to represent standard deviation; that is, the amount of variation within a given process. The higher the Sigma level, the lower the number of defects, and achieving a Six Sigma level of quality equates to a mere 3.4 defects out of one million opportunities, or nearly error-free performance (see "Sigma Levels" below). The chart on page 12 illustrates various industries and medical services with their corresponding sigma levels. Clearly, health care has ample room for improvement.

As a quality methodology, Six Sigma isn't complex, and it isn't a magic elixir. In fact, it shares similarities with other programs familiar to providers such as Total Quality Management and Continuous Quality Improvement but with several key differences (see "Ensuring Quality: a Comparison," page 14).

Six Sigma can blend with or be the next initiative after a hospital's existing quality program, but it definitely goes beyond either homegrown efforts or external initiatives. It's a rigorous, statistical approach to problem solving designed to help organizations significantly reduce the defects that drive up costs and diminish quality of care. With Six Sigma, you don't go on to the next step until you've proven empirically that you're ready. GE's approach to Six Sigma helps to clearly define, measure, analyze, improve and control (DMAIC) quality in every product, process, and transaction (see the DMAIC chart, page 14). It has essentially changed the company's "DNA," and is now the way it works and designs all products.

The Genesis of Six Sigma at Virtua

About 18 months ago, the senior executive team of Virtua held a retreat to create the long-term vision and goals for the health system and make a a single, high-performance, blended "Virtua culture" out of two very different cultures. At that time, the system was about a year old, and the initial integration of West Jersey and Memorial had taken place; the health system had one governing board and a fully integrated management team.

The team identified three measurable goals: to be recognized among the nation's top health systems; to win the New Jersey Governor's Award for Performance Excellence; and to be in the 90th percentile or above for overall patient satisfaction in all Virtua's clinical facilities.

To get there, we developed a cultural transformation program called the STAR Initiative, whose first aim has been to focus all the work of the health system on creating an outstanding patient experience, as measured in five domains:

*Excellent service

* Highest clinical quality

* A caring culture

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Sigma Comparison of Industries

* Best employee practices

*Resource stewardship

STAR's second aim is to transform Virtua into a high-performing organization, which

we have defined as an organization that makes quick decisions, removes bureaucratic barriers for employees and physicians in order to create an outstanding patient experience, and is driven by valid measurement and accountability for results.

To quickly implement the STAR Initiative, we realized we needed a process that created a framework for setting goals, defined the work needed to meet those goals, and that estabfished measures of those goals; and we needed a common language-a roadmap and a mirror to hold up to ourselves. Investigation led to a relationship with the Healthcare Solutions Group of GE Medical Systems, based in part on its success in achieving its own goals of growth, quality, and customer satisfaction over the past 15 years.

Virtua's CEO, Rich Miller, has been the sponsor and champion of the STAR initiative. It is imperative that the change initiative be "owned" by the CEO. This sends a strong message that it cannot be ignored.

My role in STAR and Six Sigma is to oversee their implementation, monitor their progress, and work with the various other leaders in the organization to make sure we are doing what we have committed to do. I am the senior executive who oversees collaboration with GE.

Working with GE gave us the ability to implement proven strategies and tools built around Six Sigma methodology. These tools have allowed Virtua to successfully institute the STAR Initiative. And we also gained some valuable assets never fully realized through previous quality or process improvement efforts. Because Six Sigma has built-in skills and monitoring capabilities, Virtua can now use this approach to achieve balanced results that don't unravel over time.

Applying Six Sigma at Virtua

The partnership between GE and Virtua began in earnest in September 2000. Several planning meetings were held between representatives of the Healthcare Solutions Group of GE Medical Systems and Virtua senior management, leading to the development of a detailed plan for the partnership, the essence of which was an agreement for GE Medical Systems representatives to teach Virtua the Six Sigma tools, including two key components, the Change Acceleration Process (CAP) and Workout.

A Workout does what its name implies-it gets extraneous work out of a process through a session led by those closest to the process or problem at hand. It uses brainstorming and a focus on the overall process of the work to remove barriers between departments and generate action steps, with management approval and a rapid-implementation timeframe.

The Change Acceleration Process, or CAP, which encompasses a range of management tools to help drive strategic change, is based on the understanding that most initiatives (62 percent by some calculations) fail because they are not accepted by key

stakeholders. The CAP techniques have all been applied to health care and are being used at Virtua. Our Six Sigma team is finding that the process actually helps to break down existing silos and get everyone speaking a common language. We expect Virtua Health to become self-sufficient in using these techniques over the next three ears. Once the initial plan was

developed, our leaders designated six full-time "Black Belts," chosen from among the organization's best managers, to learn the Six Sigma tools and lead performance improvement throughout Virtua. Black Belts and coaches run the program internally and are trained by GE. Manaement identifies a problem or issue, and then Black Belts and clinicians manage the process and involve other stakeholders as needed-from nurses to materials managers and finance directors to medical directors. From the identification of a problem or defect to the correction, the process remains consistent. Instead of stakeholders being left to solve problems in their area by themselves, and perhaps not getting the support and resources needed to be successful, they can count on the support of the Black Belts who truly represent the entire organization. This support system draws the entire organization together and Virtua has seen an improved corporate culture as a result.

Black Belts will lead Six Sigma projects and performance improvement for two years, and then will return to their former management jobs in the organization. This process serves two purposes-to provide a critical mass of individuals leading the Six Sigma process, and to train potential leaders of Virtua in advanced management techniques.

Six Sigma projects have been developed to: improve patient satisfaction in the emergency room and medical/surgical units; improve throughput (i.e., the number of cases per day) in two of the systems' busiest operating rooms; find a way to rapidly hire the best employees; improve employee retention in such critical areas as nursing; improve the revenue cycle; improve the efficiency of home health nurses; reduce errors in the use of high-- risk medications; and reduce length of stay for elderly patients with congestive heart failure (see "Six Sigma in Action" on page 13 for a step-by step example of how Six Sigma was applied to solving this problem). In addition, over 30 other Workout projects have been successfully undertaken throughout the Virtua health care system.

Virtua has also trained 60 coaches who are experts in CAP and Workout techniques. These part-time coaches are taking on at least four Workout or CAP sessions each year, helping to solve a wide range of problems throughout the organization and leading change. This represents an investment in our employees. Enabling our entire organization through these skills is one of the hallmarks of Six Sigma.

While there is a beginning to the Six Sigma process, there is no end, as we've come to expect from other quality assurance approaches. After people are trained internally and management or employees identify a problem or a hospital service that needs to be improved, the Black Belts sit down with the people responsible for those areas and

evaluate the problems using the Workout or CAP methods.

Speaking Their Language: Six Sigma and the Board

Perhaps the most important result of the STAR and Six Sigma implementation is that it has given our trustees "tangibles" they can get their hands around. Most trustees are business people who understand and are comfortable with income statements and balance sheets. They want clarity, hard facts, and numbers. Other change initiatives are often vague and lack the kind of goal-setting, progress, and tracking measures upon which the Six Sigma process depends.

The Six Sigma methodology provides detailed measures allowing trustees to:

* Be generally informed about the project, process, and projected outcomes in all domains of the health care system

* Participate in goal setting

* Understand how to interpret quality

* Base their directives on hard information

* Evaluate progress and judge success

One of the board's most important roles is to ensure that the health system is serving the community. The evidence generated by Six Sigma gives trustees the ability to show the community an unwavering commitment to both quality and fiduciary responsibility. The process provides them with proof that can be shared with the community and takes trustees out of the boardroom to understand what is happening on the front lines. Without such a program, trustees have a difficult time obtaining the information they need to make good decisions and convey results with confidence.

[Sidebar]Last year, as Virtua began the process of selecting a project linked to its key organizational objectives, senior execs decided to focus on reducing length of stay and denials of payment by Medicare and managed care companies-one of the areas we'd targeted for improvement. The project we chose involved reducing Medicare patients' lengths of stay for congestive heart failure (CHF). We needed to understand through empirical evidence what factors were extending care unnecessarily. We had to look at the sequence of events that might prevent one patient from returning home sooner than another. This particular project was determined during the Define and Measure phases of Six Sigma training, since we knew we had access to an appropriate amount of data and could track the information through several key elements, including diagnosis, physician, and hospital. These phases of the project took about four weeks to complete

and involved gathering the right data and using them to point our efforts in the right direction. We used the Pareto analysis initially, which led to identifying the CHF DRG as having significant impact and room for adjustment. The analysis also led to our decision to concentrate on one hospital in the system to achieve the greatest improvement. STEP 2: LOOKING FOR CLUES

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Ensuring Quality: A Comparison

[Sidebar]Six Sigma in Action--Reducing Length of Stay for Medicare CHF Patients

[Sidebar]To understand how Six Sigma works, it's helpful to follow a case study project from conception to completion, looking at how Virtua identified and addressed a particular problem.

[Sidebar]STEP 1: PROJECT SELECTION

[Sidebar]With the target identified, we formed a multidisciplinary team to tackle the project. The chief operating officer became the project's sponsor, and the assistant vice president for case management was the person responsible for implementing the necessary changes in procedures. The team also included case managers, clinicians, and a data analyst-about 10 people in all. We used the existing steering committee already formed to review length of stay and resource use. In the Analysis phase, we used data and statistical tools to help us take a closer and more accurate look at core elements of the process. It's important to note here that Six Sigma also involves a pattern of "train and do, then repeat." Instead of being abstract, the training is tied to an actual project, and concepts are reinforced as they're applied to actual challenges. To help the team uncover reasons for variation in lengths of stay and bring some controls into care processes, we looked at various factors that might contribute to CHF length of stay. We used a "fishbone" diagram to help the team delve into cause and effect, looking for those critical factors or "X's" (i.e., determinants of length of stay) that would yield the best measurement and results. Many "X's" floated across the lens, and as we continually refocused, we analyzed and correlated such factors as different physicians, shifts, and days of the week for admission. This led to exploring issues of testing and physician availability on the weekends, which proved to be important.

[Sidebar]STEP 3: CHANGING FOR THE BETTER

[Sidebar]Armed with statistical evidence, we moved into the Improve and Control phases of our project. Applying what we'd learned throughout the process, we were actually able to implement improvements that led to a reduction in length of stay from 6.2 days to 4.6 days for CHF patients. Our success came from making the following changes: * Early dissemination of discharge information Through our analysis, we found that one of the barriers to reducing length of stay was patient and family expectations. To improve this communication, we developed a handout and instructions for patients and family as early education and expectation-setting tools. * Achieving process-of-care improvements with staff The CHF project team used the DMAIC process and GE best practices (including CAP and Workout) to achieve improvements with the staff and clinicians. The changes they put in place allowed them to accommodate the variables inherent in a complex care situation. * Development of a specific protocol for nurses To reduce variability and standardize the care patients receive when they have CHF, the team developed a specific protocol to follow. Analysis illustrated that the sequence of

tests and treatments the majority of patients require must be done quickly to minimize waste and maximize benefit. * Distributing information on post-hospital care Patients with congestive heart failure tend to be older, and for a variety of reasons-from germ exposure to unfamiliar surroundings-hospitals can be hazardous to them. It's important to discharge them expeditiously once appropriate treatment has been given, and then to focus on the importance of post-- hospital care. Our team found that some discharge delays were the result of uncoordinated post-discharge services. To improve this situation and help the patient and family make appropriate preparations, we assembled a variety of useful information and made it available to patients early, so they would know what options were available with respect to home health, physician followup visits, and other services. Throughout every phase of this project, we relied heavily not only on the data, but on the leadership of Virtua Black Belts and participating physicians, since they drive the clinical decisions for the organization. Testing also affects how efficiently CHF patient treatment and discharge happens, so we held a Workout session to identify and address issues concerning accurate and efficient test results. The group identified ways to improve report turnaround time, an issue that can affect not only length of stay, but also resource use, patient satisfaction, and clinical outcomes.

Six Sigma in health care

Loay Sehwail,  Camille DeYong. International Journal of Health Care Quality Assurance. Bradford: 2003.Vol.16, Iss. 6;  pg. I, 5 pgs

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Subjects: Six Sigma,  Hospitals,  Pilot projects,  Health care,  Case studies

Classification Codes 5320   Quality control ,  8320   Health care industry ,  9190   United States ,  9110   Company specific

Locations: United States,  US

Companies: Mount Carmel Health System-Columbus OH (NAICS: 622110 )

Author(s): Loay Sehwail,  Camille DeYong

Document types: Feature

Publication title: International Journal of Health Care Quality Assurance. Bradford: 2003. Vol. 16, Iss.

Supplement: Leadership

Source type: Periodical

ISSN/ISBN: 09526862

ProQuest document ID: 521161341

Text Word Count 2593

Document URL: http://80-proquest.umi.com.ezproxy.mnl.umkc.edu/pqdlink?did=521161341&sid=8&Fmt=4&clientId=45248&RQT=309&VName=PQD

Abstract (Document Summary)

Six Sigma, originally initiated by Motorola and General Electric, offers a process improvement strategy that has been successfully applied in manufacturing. Services firms have recently trended toward Six Sigma methodology for internal processes and consumer centric. This paper discusses implementing Six Sigma in the healthcare sector. It introduces the challenges that face implementing the Six Sigma in services, with a special focus on the health-care industry, and the application of Six Sigma in health care. A case study about Mount Carmel Health System's successful implementation of Six Sigma is presented. Finally, the paper concludes with the potential of Six Sigma in health care. [PUBLICATION ABSTRACT]

Full Text (2593   words)

Copyright MCB UP Limited (MCB) 2003 [Headnote]Keywords Health services sector, Process management, Hospitals, Quality systems

[Headnote]Abstract

[Headnote]Six Sigma, originally initiated by Motorola and General Electric, offers a process improvement strategy that has been successfully applied in manufacturing. Service firms have recently trended toward Six Sigma methodology for internal processes and consumer centric. The paper discusses implementing Six Sigma in the health-care sector. The paper introduces the challenges that face implementing Six Sigma in services, with a special focus on the health-care industry, and the application of Six Sigma in health care. A case study about Mount Carmel Health System's successful implementation of Six Sigma is presented. Finally, the paper concludes with the potential of Six Sigma in health care.

1. Introduction

In recent years, there has been much interest in the applications of Six Sigma statistical

techniques to process improvement (Breyfogle, 1999). Traditional manufacturing firms embrace Six Sigma as a vital process improvement mechanism. By applying the same principles found in Six Sigma, many service focused companies obtain similar improvements, including reduced waste in internal processes and improved customer-facing metrics (Operations Management Roundtable, 2002).

Six Sigma principles can be applied in healthcare organizations to improve their financial and operational performance. Six Sigma identifies and aligns improvement initiatives with strategic objectives and business goals and looks at key processes across the entire system. Six Sigma examines quality, as defined by the customer, in order to focus on the requirements and expectations that are truly critical and measurable. Disciplined methodologies and aggressive variation reduction can speed improvement efforts and sustain gains.

Appropriately implemented, Six Sigma clearly produces benefits in terms of better operational efficiency, cost effectiveness and higher processes quality. Also, it can directly impact clinical areas such as infection control, medication delivery (Kooy and Pexton, 2002), medication administration and laboratory processing (Buck, 2001).

2. Challenges of implementing Six Sigma in service industries

Manufacturing firms that successfully implemented Six Sigma generally followed the following three initiatives (Operations Management Roundtable, 2002):

1 Focus on selecting and measuring the correct metrics. The define, measure, analyze, improve and control methods (DMAIC) present a clear strategy for Six Sigma implementation. While bottom line numbers such as sales and revenues indicate the current financial health of the company, process measurements create lead indicators and drives waste out of processes without drastic cost cuts.

2 Create a process-oriented, data-based driver for change. Six Sigma implementation cause companies to view change differently within their organization. To make a successful implementation, companies apply principles like: implementation efforts must be driven by senior managers, Six Sigma must be integrated with existing initiatives and business strategies, efforts must be lead by full time trained team leaders (champions), and supported by frame work of process thinking (DMAIC).

3 Identify the benefits and work to maintain the financial results. After defining the metrics and creating a cultural change within their organizations, companies must capture the financial rewards of Six Sigma, and continue to maintain these savings over time.

Despite demonstrable benefits seen in service focused environments, manufacturing continues to be the focus of Six Sigma initiatives. Implementing Six Sigma in service industries face a lot of challenges. The following are the major three challenges when

companies implement Six Sigma in a service focused environment (Operations Management Roundtable, 2002):

1 Service (non-production) focused environments struggle with metrics identification. Companies in service industries are faced with two main challenges in selecting appropriate metrics:

Creating a measurement of a process. For a production focused Six Sigma project, companies are able to count product defects as the measurement. For internal processes in a service environment, firms struggle to identify processes which can be measured in terms of defects per million.

Dealing with customer variability. For many service companies, Six Sigma applies to customer service metrics. As a result, response differences (and defects) cannot be segmented individually due to greater variability of responses.

2 Non-manufacturing firms face difficulties with creating cultural change and creating Six Sigma leaders. The most important element in shaping the vision of a Six Sigma culture is the creation of new behaviors that will help achieve the new goals and mission. Creating new behaviors is when resistance can begin.

3 Non-production focused environments fail to capture the benefits of Six Sigma application. Six Sigma projects must show cost savings. Companies have found difficulty in the past with other quality improvement strategies which did not demonstrate value. Six Sigma projects often require time and patience before results are demonstrable, and before employees see the progress of their work. Companies that do not create and reach goals for the financial benefits of Six Sigma may find themselves abandoning the projects soon after implementation.

3. Six Sigma in health care

3.1 From manufacturing to health care

Six Sigma came slowly to health care and initially was met with some skepticism. This hesitancy came from disparities between processes driven by humans versus automated or engineered processes. In manufacturing, it is quite possible to eliminate most of human variability through automation, creating precise measurement of assignable causes of variation. In health care, however, the delivery of patient care is largely a human process, and the causes of variability are often more subtle and difficult to quantify.

The first health-care organization to implement Six Sigma fully into its culture was Commonwealth Health Corp. (CHC) with partnership with General Electric. CHC has realized improvements in excess of $1.2 million, improved radiology throughput by 33 per cent and decreased cost per radiology procedure by 21.5 per cent (Thomerson,

2001).

The challenge for health-care organizations as they began to embrace Six Sigma was to find a way to leverage the data to drive human behavior. Where the approach seems to have had greatest success, providers combined a strong technical strategy (Six Sigma) with a strong cultural strategy, such as change acceleration process, and a sound operational mechanism, such as GE Medical Systems' Work-out.

Leveraging all three aspects has led to notable results. Most projects, however, involved optimizing existing processes and retaining systems and structures bound by capital investment and traditional grouping by function. A hospital's IT system, for example, may not fully support changing a given process, but the facility might decide simply to optimize around it until the investment is retired (Stah et al., 2003).

3.2 Applications In health care

The DMAIC (define, measure, analyze, improve and control) approach works quite well for any service line or process that can furnish measurable response variables. Generally, four groups of metrics or response variables in health care may define a delivery system's performance:

1 Service level. Service level metrics indicate the ability of the system's performance to meet the expectations of patients, referring physicians and other stakeholders, critical to quality parameters (CTQs). Each set of metrics has specific parameters. Service level indicators may be generalized as access to care, wait time, service time and information conveyance time.

2 Service cost. Service cost metrics indicate the cost of the system with a performance that meets the expectations of patients. Service cost indicators include cost per unit of service, labor productivity and other factors associated with the cost of providing service.

3 Customer satisfaction. Indicators may be segmented into specific groups such as patient and family, referring physician, staff and payer.

4 Clinical excellence. Indicators may relate to a particular treatment pathway or department, such as compliance with guidelines for prescription of aspirin to myocardial infarction patients or reduction of rates of infection contracted in a hospital or other health-care facility.

Most health-care organizations measure performance using some combination from these four groups, but such analysis can be misleading since the metrics often represent an average. Customers rarely experience the average performance of a system. Instead, customers tend to experience the variability. Figure 1, is a samples metric from an

emergency department (Stab et al., 2003).

3.3 Typical projects and benefits

Six Sigma projects in health care are focusing on direct care delivery, administrative support, and financial administration (Pexton, 2000). Examples of beneficial Six Sigma projects in healthcare are included in Table I.

Many health-care organizations embraced the Six Sigma challenge within their processes, examples include:

The University of Michigan Medical Center;

Yale-New Haven Health System;

Mount Carmel Medical Center (Columbus Ohio), Charleston Area Medical Center (WV); Virtua Health (NJ/PA);

Wellmark Blue Cross Blue Shield (CA);

Luther Midelfort/Mayo Health System (MN/WI);

Froedert Medical Center; and

Palomar Pomerado Health (San Diego, California).

4. Success stories

In the Spring of 2000, Mount Carmel Health System, a three-hospital system in Columbus, Ohio with 7,300 employees and a medical staff of 1,200 physicians, was experiencing severe financial challenges. The senior management team realized that they needed to improve their financial performance drastically, incremental improvement was not going to be sufficient, they needed a breakthrough level of improvement. They came to the conclusion that Six Sigma had the potential to help the organization achieve breakthrough results. Mount Carmel selected Breakthrough Management Group (BMG), to help facilitate their deployment of Six Sigma throughout the organization, a process that began in the summer of 2000 (Lazarus and Stamps, 2002a, b).

Management support

The deployment began with a two-day broad overview of Six Sigma system for the senior management team, ensuring buy-in and support for the implementation. The chief quality officer was selected to provide executive oversight of the deployment, and a vice president's position was converted into the dedicated role of vice president of Six Sigma

to direct the day-to-day implementation activities.

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Figure 1

Next, an in-depth, week-long training session was held for those within the organization who would likely become Six Sigma champions responsible for identifying and overseeing Six Sigma projects. This group mostly included the senior management team as well as vice presidents (currently there are 16 Six Sigma champions).

A cross departmental Six Sigma core team from finance, human resources, information technology, communications, as well as learning and education was formed, with the following responsibilities:

developing job descriptions and a compensation program for Six Sigma black belts;

preparing the strategy for training black belts;

ensuring the information technology resources necessary to track Six Sigma projects;

developing the tools and metrics for measuring and validating the financial returns of Six Sigma projects; and

preparing a strategy for communicating Six Sigma to Mount Carmel's internal stakeholders: managers, employees, and physicians.

Training

A total of 44 employees from among the organization's best staff were selected for training, to serve as black belts, and an additional four employees to serve as brown belts. While black belts assume their positions on a full-time basis in working on Six Sigma projects, brown belts retain their functional responsibilities and fulfill their brown belt responsibilities part-time in helping scope projects.

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Table I

The black belts and brown belts received four weeks of intensive training, one week each month for four months, while spending the other three weeks applying what they were learning by working on an actual Six Sigma project during the training period. The first wave of black belts graduated in March 2001, and the second wave in July 2001.

Organization-wide deployment

Rather than limiting the implementation of Six Sigma to one department, Mount Carmel adopted an organization-wide deployment. All business units across the organization have been expected to use the Six Sigma methodology and the black belt resources to tackle business problems that drag down financial performance and act as a source of patient, employee, and physician dissatisfaction.

Projects and financial benefits

During the first year of the deployment, Six Sigma champions selected business problems that were their biggest operational headaches. Now in the second year of implementation, they are taking a more strategic approach by selecting Six Sigma projects based on key business themes.

During the strategic planning cycle for the next fiscal year beginning, Six Sigma champions have identified six key business themes on which Six Sigma projects will concentrate:

1 revenue enhancement;

2 bad debt reduction;

3 patient throughput in all operational units;

4 labor/right staffing;

5 labor retention and recruitment; and

6 patient safety.

To date, Mount Carmel's Six Sigma projects have included:

Several claims-processing projects in the organization's Medicare HMO, employed

primary care physician practices, and behavioral health business.

Processing time in central scheduling.

Claims denials due to patient type changes and long-stay observations.

Discharging throughput to decrease bottlenecks in the emergency department.

Implementing of a procedure-based delivery system in the surgery area to help ensure supplies are present when needed during an operation.

Enhancing clinical documentation to ensure it matches the services rendered.

Making clinical laboratory results available according to the requesting physician's needs, enabling the physician to make timely decisions for patient discharge or continued treatment.

Reducing cycle time in various inpatient and outpatient diagnostic areas.

The three major benefits that Mount Carmel Health System has realized from their six sigma initiatives can be summarized as:

1 A financial return of $3.1 million with expectations for these financial returns to grow rapidly as more Six Sigma projects are completed.

2 Increased employee and physician satisfaction, as they have begun to fix problems in operational processes that have been a source of frustration and dissatisfaction for them as they do their jobs. For example, employee retention has improved.

3 Six Sigma is now the established methodology in the organization's Performance Improvement Plan which is reviewed by the Joint Commission on Accreditation of Healthcare Organizations.

5. Conclusion

Six Sigma has proven its benefits in health care through successful implementation of many healthcare providers. Appropriately implemented, Six Sigma clearly produces benefits in terms of better operational efficiency, cost effectiveness and higher processes quality. Six Sigma initiatives in health-care companies may start as a mean to improve internal process, but eventually Six Sigma becomes an indicator of future performance and growth.

In conclusion, applications of Six Sigma are extremely powerful in producing benefits to health-care organizations. Health-care organizations commitment and extensive training to their employees to Six Sigma will continue to result in short term and long

term benefits.

[Sidebar]The research register for this journal is available at http://www.emeraldinsight.com.ezproxy.mnl.umkc.edu/researchregisters

[Sidebar]The current issue and full text archive of this journal is available at http://www.emeraldinsight.com.ezproxy.mnl.umkc.edu/1366-0756.htm

[Reference]References

[Reference]Breyfogle, F.W. (1999), Implementing Six Sigma: Smarter Solutions Using Statistical Methods, John Wiley & Sons, New York, NY. Buck, C. (2001), -Application of Six Sigma to reduce medical errors", Annual Quality Congress Proceedings, Vol. 55, pp. 739-42. Kooy, M. and Pexton, C. (2002), Using Six Sigma to Improve Clinical Quality and Outcomes, GE Medical Systems Healthcare Services, available at: www.gemedicalsystems.com/ prod-sol/hcare/pdf/Six_Sigma-InHealthcare_ISSSP_August_2002.pdf (accessed 21 February 2003). Lazarus, LR. and Stamps, B. (2002a), "The promise of Six Sigma", Managed Healthcare Executive, Vol. 12 No. 1, pp. 27-30. Lazarus, LR. and Stamps, B. (2002b), "The promise of Six Sigma: getting better faster", Extra Ordinary Sense, Vol. 3, pp. 3-29. Operations Management Roundtable (2002), "Six Sigma applications in non-production focused environments", Decision Support Memorandum.

[Reference]Pexton, C. (2000), Performance Improvement at Work, GE Medical Systems Information Technologies, available at: www. gemedicalsystems.com/prod_sol/hcare/pdf/ Six_Sigma__In_Healthcare_ISSSP_August_ 2002.pdf (accessed 21 February 2003). Stah, R., Bradely, S. and Pexton, C. (2003), "Healthcare's horizon", Six Sigma Forum Magazine, Vol. 2 No. 2, pp. 1-10. Thomerson, L.D. (2001), "Journey for excellence: Kentucky's Commonwealth Health Corporation adopts Six Sigma approach", Annual Quality Congress Proceedings, Vol. 55, pp. 152-8.

[Reference]Further reading

[Reference]Frabotta, D. (2002), "Six Sigma set for growth", Managed Healthcare Executive, Vol. 12 No. 10, pp. 10-11.

[Author Affiliation]Loay Sehwail

[Author Affiliation]School of Industrial Engineering and Management, Oklahoma State University, Stillwater, Oklahoma, USA

[Author Affiliation]Camille DeYong

[Author Affiliation]Oklahoma State University, School of Industrial Engineering and Management, Stillwater, Oklahoma, USA

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Six Sigma: It's real, it's data-driven, and it's here

Mark Hagland. Health Care Strategic Management. Chicago: Dec 2005.Vol.23, Iss. 12;  pg. 1, 5 pgs

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Subjects: Hospitals,  Work methods improvement,  Strategic management,  

Classification Codes 9190   United States ,  8320   Health care industry ,  9110   Company specific ,  5320   Quality control

Locations: United States--US

Companies: Mount Carmel Health System-Columbus OH (NAICS: 622110 )

Author(s): Mark Hagland

Document types: Cover Story

Publication title: Health Care Strategic Management. Chicago: Dec 2005. Vol. 23, Iss. 12;  pg. 1, 5 pgs

Source type: Periodical

ISSN/ISBN: 07421478

ProQuest document ID: 958970691

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Abstract (Document Summary)

When chief quality officer Jeffrey Burnich, MD, began leading his colleagues at Mount Carmel Health System in Columbus, OH, down the path of quality improvement based on Six Sigma principles, he was venturing into virtually unknown territory. The basic idea of the Six Sigma quality improvement strategy is to strive for perfection by measuring how many defects exist in a process -- and then eliminating them. Along the way to implementing the strategy, Burnich and his colleagues have made tremendous improvements in cost-effectiveness, productivity, and process improvement. Interestingly, Burnich notes that he has had excellent experiences in recruiting practicing physicians to learn Six Sigma techniques and get involved in projects because of the rigorously data-driven, objective character of Six Sigma. The improvements Six Sigma has brought to the organization are ones on which the organization's future depends.

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Copyright Health Care Strategic Management Dec 2005 [Headnote]Market memo

When Jeffrey Burnich, MD, began leading his colleagues at Mount Carmel Health System in Columbus, OH, down the path of quality improvement based on Six Sigma principles, he was venturing into virtually unknown territory.

That was June 2000. Since then, Burnich and his colleagues have documented an addition of more than $62.5 million to the organization's bottom line.

The three-hospital, 9,000-employee integrated health system was the first hospital-based organization in the country to comprehensively adopt Six Sigma strategies and implement them organizationwide. It remains a model for the dozens of hospital organizations that have since moved to implement the leading-edge improvement initiative.

The quest for perfection

The Six Sigma quality improvement strategy was born in the mid-1980s at the Schaumburg, IL-based Motorola Corporation. The basic idea is to strive for perfection by measuring how many defects exist in a process-and then eliminating them.

The word "sigma" is a statistical term measuring how far a given process deviates from perfection. To achieve "Six Sigma" quality, a process must produce no more than 3.4 defects per million parts.

The concept took hold in the manufacturing industry and was used by such leaders as the Ford Motor Corporation, General Electric, Caterpillar, and Honeywell. It spread throughout the service sector and was adopted across a range of industries.

With eye-popping bottom-line results and numerous success stories to its credit, Six Sigma is now proving itself in healthcare, in a way that total quality management (TQM), continuous quality improvement (CQI), reengineering, and other improvement strategies never did.

Those who have successfully implemented the process say there's simply no better way to improve operational efficiency, cost-savings, profitability, and care and service quality.

Mount Carmel's success story

At Mount Carmel, Chief Quality Officer Burnich and his colleagues have used Six Sigma to complete 555 projects to date, leading to their impressive hard cost savings and revenue improvements.

The $62.5 million figure does not include soft gains, such as increased clinician and

patient satisfaction, or enhanced physician referrals.

Sixty percent of the total comes from top-line revenue growth and 40% from cost savings. Further, no one at Mount Carmel has lost his or her job since Six Sigma caught on there.

For Burnich and his colleagues, the point has been to build successes and cement buy-in. And successes were desperately needed. In fact, the impetus for starting down the Six Sigma path was pure financial urgency.

"In the spring of 2000, we found we had made only $500,000 on $750 million gross margin revenue-our margins were extremely low; we were getting close to the watermark there," Burnich recalls.

It was a difficult time for the entire local market, with the health system's competitors losing tens of millions of dollars at the same time because of a worsening reimbursement environment.

The health system had already eliminated 200 positions, but Burnich and his colleagues in senior management didn't expect to achieve sustained long-term gains through continual layoffs.

Burnich discovered Motorola's Six Sigma seminars through professional connections. At that time, most attendees were in manufacturing or similar industries. But after talking with Six Sigma experts, Burnich and Mount Carmel's CEO, chief operating officer, and chief financial officer all agreed to try Six Sigma at their organization.

Along the way to implementing the strategy, Burnich and his colleagues have made tremendous improvements in cost-effectiveness, productivity, and process improvement.

Among the highlights of their results are the following:

* The 24% annual staff turnover rate was reduced to 10.8%

* Patient throughput through computed tomography (CT) scanners improved from 1.8 to 2.7 patients per hour (with a net annual revenue improvement of $2.4 million per scanner in use)

* A three-week patient wait time for CT scan access was reduced to one or two days

What helped make Six Sigma such a success at Mount Carmel?

"A focus on accountability, and good blocking and tackling," says Burnich. "I think having a structure that is transparent and across the enterprise means everyone has to

buy in."

In particular, he says, leadership buy-in was key.

"The CEO is 10 ft. away from my office, and he walks, talks, and breathes it, and he went through green belt training himself and leads by example," says Burnich.

In fact, Mount Caramel's CEO took a hands-on approach -he performed research and executed a project to attain his personal green belt (Six Sigma methodology involves the training of numerous individuals within an organization as they achieve different levels of mastery, from green belt to black belt to master black belt).

Interest seen growing

Perhaps a couple dozen hospitals and health systems nationwide have taken a major plunge into Six Sigma work, among them Bon secours Health System in Marriottsville, MD; Thibodaux (LA) Regional Medical Center; Charleston (WV) Area Medical Center; Virtua Health in Marlton, NJ; Northshore-LIJ Health System in Great Neck, NY; and St. Joseph Mercy Health System in Ann Arbor, MI.

What is it that is getting hospital and health system executives to take the plunge? Those in the trenches, and industry experts, say the following characteristics make Six Sigma highly appealing:

* The focus is on operational improvements that will add to the bottom line, either in terms of revenue enhancement or cost savings

* The methodology used is intensely data-driven, and a core principle is complete objectivity

* Six Sigma philosophy emphasizes examining comprehensively the processes of an organization and then attacking specifically its deficits, but in a coordinated fashion.

* Education and training are strongly emphasized, with one of the first steps being the training of a core of black and green belt experts in Six Sigma methodologies.

* The enormous gains already made in the manufacturing sector and other "hard" industries are now being replicated in healthcare, to the encouragement of healthcare executives who have tried other improvement initiatives that have not proven sustainable.

Although Six Sigma began with engineers at the Motorola Corporation as an organized method with which to eliminate manufacturing defects, it quickly spread in the late 1980s and in the 1990s to other industries and ultimately out to healthcare, as its data-driven principles and strong discipline proved themselves in other business fields.

Healthcare, long a laggard among industries in terms of standardization of processes, data availability, and information systems, has not surprisingly come relatively late to Six Sigma.

David Silverstein, president and CEO of the Breakthrough Management Group (BMG) in Longmont, CO, sees the healthcare industry's interest in Six Sigma growing.

BMG is actively working with 50 hospitals and health systems and several large health insurers on Six Sigma development. And several of BMG's client organizations have already shown sustained multimillion-dollar revenue enhancement and cost savings achievements, he notes.

"What makes Six Sigma different in healthcare is the same thing that makes it different in all industries-a relentless focus on financial results," says Silverstein. "In the past, healthcare has adopted all the same quality initiatives as every other industry and has had the same struggle trying to sustain these initiatives, because unless you can show continuous bottom-line results, it's hard to sustain the energy."

"It's easy to sustain interest across three months, but not necessarily across years. And it's the financial measures that really bring it home. We work on things to improve patient safety and clinical results, but if you can't show ongoing results, it won't last," he adds.

Indeed, one of the biggest challenges until recently, says Mount Carmel's Burnich, is that few measurements are objective in healthcare.

"We don't set spec limits [specifications that encompass upper and lower acceptable limits] around our processes, per se," he says. "We're starting to get there. So for instance, there's a Joint Commission indicator called doorto-drug time for antibiotics for someone who's diagnosed with community-acquired pneumonia. And until a few years ago, we didn't have those kinds of measurements. And in most organizations, that information has to be captured by hand. More institutions are installing information systems, at a significant expense; and over the next few years, you'll see a lot more process measures and spec limits."

Surgical services optimized in Michigan

Although some organizations, such as Mount Carmel, turned to Six Sigma to solve deep underlying process problems, others with a strong record of process improvement over time have also been lured to the methodology because of its rigor and promise.

One such organization is St. Joseph Mercy Health System, a three-hospital, not-for-profit Catholic health system based in Ann Arbor, MI.

"Six Sigma in many ways was for us the next logical step," says Kathleen Rhine, the

organization's vice president of administrative services. "We have a long history of clinical quality improvement focused on clinical indicators; we have a quality institute here. Quality improvement was in our bones."

With more than 10 years' experience in working improvement projects through the organization's quality institute, the health system's leaders have been continually "looking for new tools, new ways to be better," Rhine says.

What made Six Sigma attractive to her and her colleagues was "the systematic way you take into account the voice of the customer; and the focus on process and process metrics-especially the opportunity to focus on business processes and patient support processes, whether registration and billing or housekeeping, food services, laundry."

Rhine says she and her colleagues understood that plunging into Six Sigma would require a considerable commitment of time, money, and effort. But the idea fit perfectly with the organization's vision statement, which includes the key phrase "a remarkable patient experience," she notes.

In any case, adds Mary Lutz, the health system's Six Sigma leader, "Six Sigma is not really new-it's the packaging, the rigor, the structure, [and] that it's data-driven. We had lots of improvement initiatives with decent results, but not the long-term results."

Rhine, Lutz, and their colleagues first began investigating Six Sigma in January 2003 and began training black belt and green belt candidates the following summer; the health system currently has five full-time black belts and 15 green belts, with those individuals initially chosen from among staff in quality consulting and project leader positions and later augmented by department managers from the surgery, pharmacy, and information systems areas.

Given the broad landscape across which projects could be initiated, Rhine, Lutz, and their colleagues decided to focus on six broad themes, all of which relate to goals set out for improved patient care by the federal Institute of Medicine:

* Patient safety

* Patient centeredness

* Efficiency

* Effectiveness

* Timeliness

* Equity

"Those are organizationwide goals we've adopted and are the lenses through which we look in order to prioritize improvements," Rhine says, adding that it's important to balance each goal against the others. "You can't maximize efficiency and hurt patient safety," she explains.

In each area, Lutz says, eliminating defects in process, improving throughput, and reducing resource utilization have been process and outcome goals.

One of the areas with the fullest set of results so far has been in the surgery area, where clinician and administrative leaders agreed that there was great potential for improvement.

Among the improvements are the following:

* On-time surgical starts

* Improved operating room turnover

* The ability to add urgent cases into the surgery schedule in a more timely and efficient manner

* The optimization of surgeons' supply preference cards (which has led to significant savings through supply usage reduction)

* Enhanced surgical volume overall as a result of greater efficiency

Focus on people and resources

All those interviewed for this article agree on several key requirements for success for Six Sigma initiatives. Among other things, they say

* Six Sigma initiatives must absolutely have vocal, firm, and ongoing support both from the CEO of an organization and its other senior executives to succeed. Unlike TQM/CQI initiatives, for example, Six Sigma requires sustained, top-level commitment to succeed.

* Six Sigma goals must be closely aligned with overall organizational business and strategic goals.

* information systems must often be enhanced or further developed over time; although data collection and analysis often begins by hand, all those interviewed agree that good information systems and data analysis programs will help tremendously in the long run.

* Six Sigma success also requires sustained resource investment (though it offers the promise of more than recouping the resources invested). This includes money for education and training, as well as the dedication of full-time staff members to develop

and guide projects.

* those chosen to help lead the initiative overall and to lead individual projects must come from the cream of the crop of the organization's administrative and clinical leaders, everyone emphasizes. Six Sigma cannot succeed if it is delegated to underpowered underlings.

"From a pragmatic standpoint," says Lutz, "full-time staff really is necessary. We've heard of some people doing it with part-time black belts, [but] there is no such thing as a part-time black belt. It's a long-term initiative; commitment is required."

What's more, she says, selecting the right people and projects is absolutely critical.

"They are people who both have the ability to learn the technical skills-because there's a lot of rigor about technical skills in Six Sigma-but who also have the interpersonal and team management skills to help people envision and accomplish change-and people with influence. Sometimes it's easy to find one or the other, but it's important to screen and get both," she says.

Interestingly, Burnich notes that he has had excellent experiences in recruiting practicing physicians to learn Six Sigma techniques and get involved in projects because of the rigorously data-driven, objective character of Six Sigma.

"Physicians are scientists; they get it," he says. "The people who really need to lead this are the clinicians-the physicians, nurses, pharmacists."

In the end, says Burnich, "This is one of the hardest things I've ever done; it took a lot of energy to get this going and keep it going. But we achieved critical mass about two years ago, [whereas] if I left or our CEO left, it would still go on."

And go on it must, he says. The improvements Six Sigma has brought to the organization are ones on which the organization's future depends.

[Sidebar]Six Sigma is proving itself in healthcare in a way that total quality management and other improvement strategies never did.

[Author Affiliation]Mark Hagland is a freelance healthcare journalist based in Chicago.

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Subjects:Hospitals  Work methods improvement  Strategic

management  Case studies  Six Sigma 

Classification Codes9190 United States  8320 Health care industry 

9110 Company specific  5320 Quality control 2310 Planning

Locations:United States--US

Companies:Mount Carmel Health System-Columbus OH

NAICS:622110

Author(s):Mark Hagland

Document types:Cover Story

Language:English

Publication title:Health Care Strategic Management

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Lean Six Sigma Reduces Medication Errors

Grace Esimai. Quality Progress. Milwaukee: Apr 2005.Vol.38, Iss. 4;  pg. 51, 7 pgs

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Subjects: Case studies,  Six Sigma,  Hospitals,  Medical errors,  Quality control

Classification Codes 5320   Quality control ,  8320   Health care industry ,  9190   United States ,  9110   Company specific

Locations: United States,  US

Author(s): Grace Esimai 

Document types: Feature

Section: HEALTHCARE

Publication title: Quality Progress. Milwaukee: Apr 2005. Vol. 38, Iss. 4;  pg. 51, 7 pgs

Source type: Periodical

ISSN/ISBN: 0033524X

ProQuest document ID: 825035511

Text Word Count 2431

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Abstract (Document Summary)

Among healthcare errors, medication errors, including those made in prescriptions, pharmacy dispensing, handling by staff and handling by the patient in self-medicating situations, pose the most serious threat. Interested in quality management in several areas, management at a mid-sized hospital (which chooses to be anonymous) approved a project using lean Six Sigma to determine what changes in policy and practices might be necessary to significantly reduce these errors. The Six Sigma techniques use statistical procedures and five well-defined phases of the define, measure, analyze, improve and control roadmap to achieve profitability and quantum gains in quality, sometimes as a result of redesign of the process maps and installation of new equipment. In healthcare, the best approach appears to be error prevention using software that flags mistakes so employees will take immediate corrective action.

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Copyright American Society for Quality Apr 2005

Among Healthcare errors, medication errors, including those made in prescriptions, pharmacy dispensing, handling by staff and handling by the patient in self-medicating situations, pose the most serious threat.

Interested in quality management in several areas, management at a mid-sized hospital (which chooses to be anonymous) approved a project using lean Six Sigma to determine what changes in policy and practices might be necessary to significantly reduce these errors.

Project Team

The group tasked with making this determination was set up in two tiers: a project team overseen by a steering committee.

The steering committee consisted of members of upper management and heads of functional departments. This committee appointed employees with relevant daily floor level experience in various associated processes as members of the project team. Specifically, these individuals were involved in the processes of prescription transcription, order filling and all other stops influencing the error rate in the medication administration records (MARs).

In addition, the project team included individuals who could recommend and implement interventions to error reduction. The project team periodically reported to the steering committee.

Defining the Problem

The process of medication administration at a hospital involves six steps:

1. Selecting and procuring.

2. Storing.

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3. Ordering and transcribing.

4. Preparing and dispensing.

5. Administering the medication.

6. Monitoring medication effects.

Due to time constraints, the steering committee defined the most urgent problem as the unknown error rate in the hospital MAR. The scope of the project was to concentrate on the medication order entry (OE) process. The project team charter aimed to investigate a process to dramatically reduce MAR errors by a factor of about 1,000 by the end of the project's five-month duration.

Measuring the Baseline And Tracking Errors

Prior to the formation of this project team, the hospital's quality improvement department had mapped the pharmacy OE and the nursing MAR transcription processes. The project team reviewed and verified the process maps against the current practices and sequence of operations.

The team reviewed the errors observed in February in the pharmacy OE process. An effort was then made to more rigorously define these errors and establish the criteria for cataloging them to aid in root cause analysis and achieve better consistency in error tabulation. This attempt minimized subjectivity and thus achieved a more consistent result overall. The project team subsequently identified the following errors:

* Additional instructions: Any physician comments/instructions/indications on the original faxed medication order that are not input by pharmacy.

* Dose: Wrong dose or dose differs from original faxed medication order.

* Drug: Wrong drug (medication description differs from original faxed medication order).

* Duplicate order entry: Same medication description profiled twice with two different prescription numbers.

* Frequency: Frequency on MAR differs from original faxed medication order.

* Omissions: Certain medication is omitted from the OE process without a reason.

* Discontinuation order not carried out when received: Medication that is either indicated or implied to be discontinued may still be entered in the OE by pharmacy.

* Order not received: Faxed medication order is not received or cannot be located at the pharmacy.

* Patient: Medication order has been profiled correctly/incorrectly on the wrong patient.

* Route: Medication order has been profiled with incorrect route (intravenous or intramuscular).

The Pareto diagram of the data gathered at the start of the project is shown in Figure 1. The diagram prioritizes the relative frequency of occurrence in a bar chart for better visualization. At project initiation, the total error rate in the overall MAR process was estimated to be 0.33% or about 3,300 per million.

While reviewing weekly records, the team observed certain errors could be traced back to the pharmacy employee who committed them. The team quickly tabulated the errors and discovered a high variability in performance among these employees.

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FIGURE 1 Pharmacy Error Pareto DiagramFIGURE 2 February and March Errors By Pharmacy Employees

Some employees committed as many as 112 errors in the two-month period of February and March, while others made as few as zero errors in that same period. There were 21 employees involved with the OE process. Figure 2 shows the results.

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FIGURE 3 February and March Errors Showing Positive Trend

To protect their identities, the project team coded the employees using a simple number scheme. For immediate intervention, the team reviewed the errors during one-on-one meetings with the pharmacy employees and found the high error frequencies resulted from a misunderstanding of certain guidelines and instructions. To correct this, the pharmacy department instituted remedial education and closer supervision of employees.

The next step was to estimate the trend of the errors vs. time. Statistical methods for estimating the trend included moving averages, exponential smoothing and least squares or regression analysis. On running a regression analysis, our choice as the most

objective method, evidence of increased errors became obvious (see Figure 3).

Vital Missing Data and Metrics

The basic metric of Six Sigma identifies defects per million opportunities, which can also be represented as a percentage error rate. Error rates are computed from the ratios of the total number of errors associated with a population of transactions and the total number of transactions in the population.

To establish a context for identifying the medication OE errors (or MAR errors) at the hospital, here is an outline of the process sequence: Daily orders are faxed to the pharmacy, where they are profiled on the MAR. Nurses review the MAR and report any error findings to the pharmacy. A pharmacy technician then records the errors by type and who committed them. In this arrangement, it is very difficult to capture errors, such as forgetting to fax an order, that are committed by the nurses themselves. The pharmacy is thus blamed for every error, and there is no accountability at the nurses' end for MAR errors.

Another pertinent and vital metric, albeit elusive, is the average order cycle time. This is defined as the average time it takes the pharmacy to fill an order measured from when a physician writes a prescription to when it registers on the MAR as correct.

This metric was not available because the physicians did not write the time of the prescription. They simply wrote the date. It would be important to have such information so root causes of delays could be studied and interventions implemented.

This implementation was especially necessary because it could contribute to labor cost savings as well as the satisfaction of the internal customers (nurses), the internal vendors or customers (pharmacists) and external customers (patients).

Analyzing the Problem

Finally, after all the investigation, the project team found the root causes of all the different types of errors to be one or a combination of the following:

* There were problems with the fax machines that used regular telephone lines, and related technical problems caused unnecessary delays, duplicate order entries and nonreceipt of faxed orders in the pharmacy.

* Problems with the legibility of physicians' handwriting and use of personal nonconventional abbreviations were partly responsible for wrong doses, drugs and frequencies. Some drug errors arose from the use of generic vs. trade names.

* Distractions and interruptions during the order entry process, such as phone calls or questions and conversations with colleagues, caused omission errors, the selection of

incorrect drugs or doses from the dictionary, wrong frequency and duplicate order entries.

* Nonreconciliation among nurses and pharmacists regarding the physician's orders regarding the standard way to administer the medication, such as the route, number of times a day and when during the day.

* Other common cause and human errors such as not discontinuing orders when received due to oversight, dispensing wrong doses due to becoming used to a certain dose and selecting medication from nursing station floor stock and forgetting to note a change in dose.

During the investigation, the project team also observed the number of human errors could have arisen from stressful and dissatisfactory work conditions. The team therefore decided each of the two work groups involved should fill out a customer satisfaction survey on their perception of needs and expectations of the other group. Figures 4 and 5 give the nurses' survey results. Figures 6 and 7 display the results of the pharmacists' survey of the nurses.

It is interesting to note from Figure 5 only 3% of the nurses said the pharmacy employees were rude, contrasting with the overwhelming majority of pharmacists from Figure 7 who claimed the nurses were extremely rude (69%) and impatient (3%).

Apparently, the pharmacists at this hospital were not friendly and polite to the pharmacists as they carried out their daily duties. They seemed to fail to recognize they and the pharmacists were customers of each other, deserving the same courtesy they offer their external customers, the patients. Each group believed the other group expected them to do the impossible, understanding neither the nature of its work or its workload.

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FIGURE 4 Nurses' Satisfaction With PharmacyFIGURE 5 Things Nurses Disliked About PharmacyFIGURE 6 Pharmacists' Satisfaction With NursesFIGURE 7 Things Pharmacists Disliked About Nursing Department

Developing Error Reducing Solutions

The project team combined lean methods and Six Sigma techniques in the error reduction process. Lean methods generally aim at the identification and gradual evolutionary elimination of waste (error).

The Six Sigma techniques use statistical procedures and five well-defined phases of the define, measure, analyze, improve and control (DMAIC) roadmap to achieve profitability and quantum gains in quality, sometimes as a result of redesign of the process maps and installation of new equipment.

In healthcare, the best approach appears to be error prevention using software that flags mistakes so employees will take immediate corrective action. The project team therefore approved or recommended the following solutions:

* Institution of a high performance standard through instruction and supervision. The project team discovered factors contributing to substandard performance and increasing the error trend, including the misunderstanding of instructions and guidelines by some pharmacists. A higher performance standard was immediately instituted through instruction and supervision. This effort, using lean methods, yielded significant positive results.

* Facilitywide (full) implementation of computerized physician order management (CPOM). The project team considered the CPOM program paramount to reducing or permanently eliminating errors caused by illegibility of physicians' handwriting and faxing of handwritten orders. Timelines would be monitored because the exact time a prescription was written would be recorded, thus eliminating undue delays.

* Installation of a system to separate the fax and phone lines as an interim measure to reduce the faxing problems. We believed this step would reduce the errors related to nonreceipt of faxed orders at the pharmacy and duplicate orders, reducing man-hours and tension between the nursing and pharmacy employees.

* Unit based pharmacists and agreement on standard times of medication administration among hospital nurses and pharmacists. If the pharmacists were unit based, some understanding of each other's job and its scope would likely develop between pharmacists and the nurses in each unit. The work therefore would become streamlined, and nurses and pharmacists would know their internal customers by name-an added bonus to customer satisfaction.

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FIGURE 8 February to June Weekly Errors Showing Negative Trend

* Monthly meetings to foster better relationships between nurses and pharmacists. This will help eliminate wrong perceptions nurses and pharmacists currently hold of each others' jobs and help change a stressful workplace to a place where people work cordially as a team to achieve the common strategic goal-patient care and satisfaction.

* Designation of a pharmacy employee to serve as a telephone operator for all external calls. During the analyze phase, the team found distractions from outside phone calls caused numerous errors. A solution could be designating a pharmacy employee to take these calls so the pharmacists can concentrate on what they are doing.

Implementing and Sustaining the Solutions

Considering the available data from February to June, you can observe progress in the error reduction effort. The simple linear regression analysis of each of the errors clearly shows a downward trend (see Figure 8).

Figure 9 shows most of the errors have been dramatically reduced, with the total number dropping from 213 in February to 96 in June, a 55% reduction. Figure 9 also clearly shows the differences in absolute numbers between the February and June frequencies for each type of error.

The team further made a comparison of February and June OE errors by pharmacist. Figure 10 shows a significant reduction for most of the pharmacists. The nonpharmacist errors caused by faxing problems and recorded as "orders not received" continued to be high, although an almost 50% reduction (from 51 in February to 28 in June) was attained.

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FIGURE 9 February and June Pharmacy Order Entry Errors by Error TypeFIGURE 10 February and June Errors By Pharmacist

Other benefits of instituting a lean Six Sigma methodology at this mid-sized hospital were:

* Reversal of OE errors from an increasing to a downward trend for most types of errors.

* A decrease in the total error rate from 0.33% to 0.14% in five months.

* Estimated labor cost reductions of $550,000 (annualized at $1.32 million). It is noteworthy the current results are realized by simply creating awareness through pharmacy department meetings and fresh instructions and training to the pharmacy employees.

* Patient satisfaction.

* Improved employee morale and better relationships between nurses and pharmacists.

ACKNOWLEDGMENTS

The author thanks Ken Kipers, M.D., Victor Eriken and Chimdimnma Esimai for their useful suggestions.

Please comment

If you would like to comment on this article, please post your remarks on the Quality Progress Discussion Board at www.asq.org, or e-mail them to [email protected].

[Sidebar]In 50 Words Or Less* Medication errors pose a serious threat in healthcare.* A mid-sized hospital used lean Six Sigma to change policy and practices to reduce these errors.* After solutions were implemented, errors dropped sharply, labor costs fell, patients

were more satisfied, and employee morale improved.

[Sidebar]Each group believed the other group expected them to do the impossible, understanding neither the nature of its work or its workload.

[Reference]BIBLIOGRAPHYBarry, Robert, Amy C. Murcko and Clifford E. Brubaker, The Six Sigma Book for Healthcare, Health Administration Press, 2002.Ficalora, Joe, Joe Costello and Julien Renaud, Combining Lean and Six Sigrna Methodologies, special publication of the ASQ Statistics Division, spring 2004.Till, David W., The Recipe for Simple Business Improvement, ASQ Quality Press, 2004.

[Author Affiliation]GRACE O. ESIMAI is a senior lecturer in the department of information systems and operations management at the University of Texas at Arlington. She earned a doctorate in statistics at Iowa State University and is a memver of ASQ.

Dutch Hospital Implements Six Sigma

Jaap van den Heuvel,  Ronald J M M Does,  Søren Bisgaard. ASQ Six Sigma Forum Magazine. Milwaukee: Feb 2005.Vol.4, Iss. 2;  pg. 11, 4 pgs

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Subjects: Six Sigma,  Hospitals,  Quality of service,  Case studies

Classification Codes 9175   Western Europe ,  9110   Company specific ,  5320   Quality control ,  8320   Health care industry

Locations: Netherlands

Companies: Red Cross Hospital -Beverwijk Netherlands (Sic:622110 )

Author(s): Jaap van den Heuvel,  Ronald J M M Does,  Søren Bisgaard

Document types: Feature

Section: HEALTHCARE

Publication title: ASQ Six Sigma Forum Magazine . Milwaukee: Feb 2005. Vol. 4, Iss. 2;  pg. 11, 4 pgs

Source type: Periodical

ISSN/ISBN: 15394069

ProQuest document ID: 809418431

Text Word Count 2405

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Abstract (Document Summary)

Red Cross Hospital in Beverwijk, the Netherlands, is a 384-bed, medium-sized general hospital, with a staff of 930 and a budget of $70 million. During the past four years, Red Cross Hospital's management and employees invested significant resources in building a quality assurance system, and at the end of 2000, the hospital was awarded an ISO 9002 certification. After that, management began undertaking quality improvement projects on a regular basis, but it was doing so without the benefit of Six Sigma's project management system. Six Sigma was initiated at Red Cross Hospital by an external consulting company during a one-day training session for upper management at the end of 2001. To implement Six Sigma at Red Cross Hospital, management had to customize and adapt some of the standard Six Sigma management concepts so they better applied to the healthcare industry. Management believed its implementation of Six Sigma was successful for several reasons: 1. philosophy, 2. project management, 3. well-defined roles and responsibilities, 4. tools and techniques, 5. well-defined interfaces with the existing organization.

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Copyright American Society for Quality Feb 2005 [Headnote]EVEN SMALL PROJECTS CAN MAKE A BIG DIFFERENCE.

Red Cross Hospital in Beverwijk, the Netherlands, is a 384-bed, medium-sized general hospital, with a staff of 930 and a budget of $70 million. In addition to being a general healthcare provider, Red Cross Hospital is the base for a 25-bed national burn care center that provides services to all of the Netherlands. In 2002, it admitted 11,632 patients, performed 8,269 outpatient treatments and received 190,218 visits to its outpatient units.

During the past four years, Red Cross Hospital's management and employees invested significant resources in building a quality assurance system, and at the end of 2000, the hospital was awarded an ISO 9002 certification. After that, management began undertaking quality improvement projects on a regular basis, but it was doing so without the benefit of Six Sigma's project management system.

Life Before Six Sigma

The hospital's initial quality improvement approach appeared to work reasonably well.

However, management soon recognized its control of projects was less than effective:

* Project goals were often poorly aligned with the hospital's strategic goals.

* There was no systematic way to determine a project's relevance and contribution to the long-term strategy.

* There was no standardized procedure for evaluating a project's cost effectiveness.

* Management had difficulty making project go/no go decisions. Projects were generally initiated because management thought they would make a contribution to quality of care.

* Management was not able to access the potential savings of alternative projects.

* Once a project was started, management did not have reliable information about its status until it was finished. Each project had different milestones, and progress could not be evaluated and compared to other projects.

Management was basically navigating in the dark.

The management team and employees were frustrated because the hospital lacked a standardized project management approach. Time was frequently wasted-when each new project was started, the approach, project documentation and planning had to be developed from scratch. For that and other reasons, management had problems properly training its employees in project management. Though the hospital had organized training, the results were meager and disappointing.

Another problem was management expected employees to work on projects in addition to performing their usual duties. This might appear to be an inexpensive approach, but it seriously delayed potential savings. Ironically, management was mostly unaware of this unfortunate situation because of its poor management controls. Had management been in a position to determine the results of a project in advance, it would have been able to make more appropriate decisions about employee time allocations to projects. Fortunately, management learned employees should be relieved of some of their usual duties when working on a project.

Why Six Sigma?

Six Sigma incorporated a number of quality management techniques that helped resolve some of the problems at Red Cross Hospital. Management believed its implementation of Six Sigma was successful for several reasons:

* Philosophy: Because Six Sigma is based on scientific principles, decisions were based on facts and data instead of feelings and intuition. Projects were not initiated when

estimated savings were below management defined thresholds.

* Project management: Projects were managed strictly according to the five phases of the define, measure, analyze, improve, control (DMAIC) methodology. Each phase was completed only after specific milestones were reached.1 At any given time, it was possible to determine a specific project's progress in a unified way within departments and across the entire organization.

* Well-defined roles and responsibilities: Six Sigma assigned specific roles-Yellow Belt, Green Belt (GB), Black Belt (BB), Champion and Master Black Belt (MBB)-to those involved. Explicitly defined roles and expected contributions were important during the organizational change effort and contributed to the success of a project.

* Tools and techniques: Six Sigma employed a variety of tools and statistical techniques. Software tools were used to make the techniques available and accessible to people with little or no training.

* Well-defined interfaces with the existing organization: Six Sigma provided a detailed blueprint that linked it to the existing organization. Specifically, Six Sigma's tight project organization operated across all hierarchical layers of the hospital. All relevant information and responsibilities could be brought together while the business continued to operate.

Six Sigma was not just an idea or another trick to organize improvement projects. Its set of well-defined and well-tuned managerial instruments enhanced the results of improvement projects and, ultimately, maximized the performance of the entire organization.

To implement Six Sigma at Red Cross Hospital, management had to customize and adapt some of the standard Six Sigma management concepts so they better applied to the healthcare industry. For example, adjustments had to be made because Red Cross Hospital was much smaller than the typical organizations that implement Six Sigma.

Management also had to address concerns regarding the culture of its nonprofit, service organization and the differences between it and an industrial for-profit company's explicit focus on financial results. Fortunately, it was relatively easy to convince the skeptics by explaining that more money for the hospital means happier and healthier patients. In this respect, Red Cross Hospital's experience parallels the implementation of Six Sigma at Thibodaux Regional Medical Center in Louisiana.2

The Implementation

Six Sigma was initiated at Red Cross Hospital by an external consulting company during a one-day training session for upper management at the end of 2001. The management team consisted of two directors and the managers of the hospital's four

divisions. The quality manager was introduced to Six Sigma in January 2002, and she enthusiastically went through intensive RB training that spring.

After the quality manager completed her BB course, 16 employees enrolled in in-house GB training provided by the consulting company in September 2002. Though all GB trainees were required to participate in one Six Sigma project, one hospital director also participated in the first wave of GB projects.

During the course of two separate, three-day periods, every participant was required to produce documented results. No GB project was allowed to proceed to the subsequent phase until the preceding phase was completed. Participants had to present their results twice in front of the entire group, the second time being a presentation of their final results.

Because of the hospital's small size, teams were made up exclusively of GBs, each typically spending two days a week on the project. Considering the hospital's budget and savings potential, management used $25,000 estimated savings as its financial threshold for initiating a project. After completing the first wave, management immediately started a second group of 15 GBs in February 2003, a third group of 13 GBs in September 2003, a fourth group of 14 GBs in February 2004 and a fifth group of 17 GBs in September 2004.

The Six Sigma approach was well received by employees. The teams believed it supported them throughout the entire process of a project. The data driven approach was helpful in establishing support during the implementation of the results. The data proved convincing and, in many cases, minimized emotional resistance.

Initially, the hospital's BB performed the role of MBB on a part-time basis. This quickly proved inadequate as the number of GBs increased. Since management wanted to deploy Six Sigma relatively quickly, it decided to hire a full time MBB from outside the hospital. Fortunately, it was able to hire a BB with previous experience from DAF, a Dutch truck manufacturer now owned by Paccar. Management was comfortable employing a MBB with experience from outside the healthcare sector because the language of Six Sigma is universal and independent of industry type. Red Cross Hospital even received an offer from 3M, a company with a reputation for having successfully implemented Six Sigma, to support it in further developing its Six Sigma organization.

Outstanding Results

The first group of 16 GBs were initially involved with seven projects. One project was terminated during the course of the training because it didn't run well. This was a nice change, because in the pre-Six Sigma phase of the hospital's quality improvement initiative, such a project would have dragged on forever. The other six projects were successfully completed in February 2003. They are described briefly below. More

details about these and other projects can be found in a recent article in Quality and Reliability Engineering International.3

Shortening the length of stay of COPD patients: Patients with chronic obstructive pulmonary disease (COPD) were admitted to either the pulmonary or internal medicine department due to capacity problems in the former. A statistical analysis done by the first team showed a significant difference in the admission time between the two departments. The average stay in the pulmonary department was two days shorter than that in the internal medicine department. A further statistical analysis showed this difference was not due to patient characteristics or physicians. The pulmonary department was just better at treating pulmonary patients.

The hospital rebalanced the bed capacity so all COPD patients could be to be admitted to the pulmonary department. After this change, in-patient days were saved and more admissions were possible. The annual savings was estimated at $40,000.

Reducing errors in invoices from temp agencies: After an intensive investigation, the second team discovered a considerable number of incorrect invoices from temporary agencies. The errors consistently fell in favor of the agencies and cost the hospital a lot of money to fix. The hospital designed and implemented an improved declaration form that is now required by all agencies contracting with it. In addition to the annual savings estimated at $75,000, Red Cross Hospital experienced a one-time savings of $35,000 due to a refund from the agencies.

Revision of the terms of payment: An analysis by the third team revealed the hospital's suppliers were paid under a variety of terms due to the lack of a uniform payment policy. A standard policy was established, and a number of improvements were implemented. The total savings so far is $35,000 and continues to increase.

Reducing the number of mistakes in invoices: Red Cross Hospital issues 250,000 invoices to patients and insurance companies a year. The fourth team discovered 9% of the invoices were refused and sent back due to the hospital's mistakes. Given the large number of invoices and mistakes, the true statistics lovers saw their finest hour during this project. More than 100 percentage points of improvement were identified, a number of which are still being worked on today. At this time, less than 1% of the invoices are refused, and the savings has exceeded $200,000.

Rooming-in in the children's department: A data analysis done by the fifth team revealed a child's length of stay decreased when parents were permitted to stay with their hospitalized children over night. Measures were then implemented to facilitate the presence of parents. Armed with the data, insurance companies agreed to pay 80% of the cost for the extra services. The significant decrease in the number of admission days allowed the hospital to admit more children and boost its revenue. The total annual savings was estimated to be about $30,000.

Reducing the number of patients on intravenous antibiotics: Intravenous antibiotics are much more expensive than oral medication. The sixth team found a number of patients who used intravenous antibiotics could have been transferred to oral medication earlier than they were. An analysis showed the internal medicine department was better than the surgical department at managing this process. Further analysis revealed the internal medicine department had a strictly followed standard operating procedure (SOP) for switching between intravenous and oral medication, and the surgical department did not have an SOP. The protocol developed and used by the internal medicine department was adopted as the SOP throughout the hospital. The total annual saving was estimated at $25,000.

Although each of these savings individually may seem relatively modest, they added up to a significant amount. Each required only minor changes and adjustments to the operation and management of the hospital, and more importantly, all the improvement projects provided significant but less tangible benefits to the hospital's management and its customers-the patients.

The six improvement projects illustrate a $25,000 minimum level of revenue per project can easily be met, and much larger amounts are also possible. Projects in patient care and the administrative departments are also feasible. Because employees are free to suggest ideas for projects, management expects an improved selection of projects will further enhance revenue in the future.

The results at Red Cross Hospital are encouraging. The hospital's management experienced no significant problems implementing Six Sigma in the nonprofit service organization, and employees were enthusiastic and considered its use a major advantage in managing and executing improvement projects. There is no doubt Red Cross Hospital will continue to use Six Sigma and ISO 9000 as the core of its quality management system.

ACKNOWLEDGMENTS

The work described in this article was supported by Red Cross Hospital, the Institute for Business and Industrial Statistics at the University of Amsterdam, the Isenberg School of Management at the University of Massachusetts Amherst and the European Community (EC) through the Thematic Network-Pro-ENBIS-EC (contract number G6RT-CT-2001-05059).

WHAT DO YOU THINK OF THIS ARTICLE? Please share your comments and thoughts with the editor by e-mailing [email protected].

[Sidebar]THE DATA DRIVEN APPROACH WAS HELPFUL IN ESTABLISHING SUPPORT DURING THE IMPLEMENTATION OF THE RESULTS. THE DATA PROVED CONVINCING AND, IN MANY CASES, MINIMIZED EMOTIONAL

RESISTANCE.

[Reference]REFERENCES1. Mikel Harry, The Vision of Six Sigma, Tri Star, 1997.2. Greg Stock, "Taking Performance to a Higher Level," Six Sigma Forum Magazine, Vol. 1, No. 3, pp. 23-26.3. Jaap van den Heuvel, Ronald J.M.M. Does and M.B. Vermaat, "Six Sigma in a Dutch Hospital: Does It Work in the Nursing Department?" Quality and Reliability Engineering International, Vol. 20, No. 5, pp. 419-426.BIBLIOGRAPHYBarry, Robert, A.C. Murcko and C.E. Brubaker, The Six Sigma Book for Healthcare, Health Administration Press, 2002.Does, Ronald J.M.M., Edwin R. Van den Heuvel, Jeroen De Mast and Søren Bisgaard, "Comparing Nonmanufacturing With Traditional Applications of Six Sigma," Quality Engineering, Vol. 15, No. 1, pp. 177-182.General Electric's website, www.gehealthcare.com/pr?d_sol/hcare/ sixsigma.iSixSigma's website, http://healthcare.isixsigma.com.Kabcenell, Andrea, and Donald W. Berwick, "Pursuing Perfection in Healthcare," Six Sigma Forum Magazine, Vol. 1, No. 3, pp. 18-22.Stahl, Richard, MD, Bradley Schultz and Carolyn Pexton, "Healthcare's Horizon," Six Sigma Forum Magazine, Vol. 2, No. 2, pp. 17-26.

[Author Affiliation]By Jaap van den Heuvel, Red Cross Hospital; Ronald J.M.M. Does, University of Amsterdam; and Søren Bisgaard, University of Massachusetts Amherst and University of Amsterdam

Six Sigma deployment in a large integrated health system

Alan H Cooper. Quality Congress. ASQ's ... Annual Quality Congress Proceedings. Milwaukee: 2002. pg. 71, 7 pgs

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Subjects: Changes,  Hospital systems ,  Quality standards,  Corporate culture

Classification Codes 2500   Organizational behavior ,  5320   Quality control ,  6200   Training & development industry,  9130   Experimental/theoretical

Companies: North Shore-Long Island Jewish Health System (NAICS: 622110 )

Author(s): Alan H Cooper

Document types: Feature

Publication title: Quality Congress. ASQ's ... Annual Quality Congress Proceedings. Milwaukee: 2002

Source type: Periodical

ProQuest document ID: 162055861

Text Word Count 4502

Document URL: http://80-proquest.umi.com.ezproxy.mnl.umkc.edu/pqdlink?did=162055861&sid=9&Fmt=3&clientId=45248&RQT=309&VName=PQD

Abstract (Document Summary)

This paper reports on the establishment and deployment of a Six Sigma quality initiative within the third largest not-for-profit secular health system in the US. The successes, challenges, and pitfalls of a large-scale implementation are discussed, as well as the current progress of the implementation effort. The North Shore-Long Island Jewish Health System has a service area of 5.2 million people and covers 2200 square miles on Long Island and New York City. In early 2001 the Health System sent two employees to Six Sigma training with ASQ. During their training, the first Health System project was completed below the radar as the employee training and the project were not public knowledge throughout the System. Although the literature was impressive, leadership felt that the best way to introduce Six Sigma was with a successful project within the Health System. This approach was chosen due to the fact that a well-established quality management program already existed within the System.

Full Text (4502   words)

Copyright American Society for Quality 2002 [Headnote]KEY WORDS: Change, Resistance, Challenges, Pitfalls SUMMARY

[Headnote]This paper reports on the establishment and deployment of a Six Sigma quality initiative within the third largest not-for-profit secular health system in the United States. The successes, challenges, and pitfalls of a largescale implementation are discussed, as well as the current progress of the implementation effort.

BACKGROUND OF THE HEALTH SYSTEM

The North Shore - Long Island Jewish Health System is the Nation's third largest not-

for-profit secular healthcare system, and the largest integrated healthcare network in the Northeast. The System has a service area of 5.2 million people and covers 2200 square miles on Long Island and New York City. North Shore - LU has an annual operating budget of $3.2 billion and has over 30,000 employees and an additional 5,000 physicians. It is the largest employer on Long Island and the 10 largest employer in the City of New York. The System is comprised of three tertiary hospitals, nine community hospitals, two specialty hospitals (children's and psychiatric), four affiliate hospitals, two research institutes, two long-term care facilities, a core laboratory, the East's largest Emergency Medical Service, and seven home health agencies. Approximately 24,000 babies are delivered annually, and the System sees approximately 3.6 million patients per year. The Joint Commission on Accreditation of Healthcare Organizations has honored North Shore - LU with the Ernest Codman award for quality, and the Nursing profession has honored the two tertiary centers with Magnet Recognition for Excellence in Nursing Service.

In January of this year, the architect of the Health System's growth stepped down and was succeeded by the System's Executive Vice President and Chief Operating Officer, Michael Dowling. Mr. Dowling's vision is to bring the successes of private industry into the healthcare setting. As he stated, "...at the end of the day the objective is improved quality and improved bottom line". One of his first steps towards realizing his strategic vision was to establish the Center for Learning and Innovation, a "corporate university" created with the assistance of Harvard University and General Electric's Healthcare Leadership Team. The development of the Center had begun a year earlier with the establishment of a steering committee and a "trial run" of Six Sigma methodology.

THE EARLY YEARS

In early 2001 the Health System sent two employees to Six Sigma training with ASQ. During their training, the first Health System project was completed "below the radar" as the employee training and the project were not public knowledge throughout the System. Although the literature was impressive, leadership felt that the best way to introduce Six Sigma was with a successful project within the Health System. This approach was chosen due to the fact that a well-established quality management program already existed within the System.

Just prior to completion of the initial Six Sigma project, internal communications began to rollout regarding the Center for Learning and Innovation. Within the communication material was a section labeled "Six Sigma Institute", which generated substantial interest, and controversy, throughout the Health System. Word spread quickly about the "new" methodology that was on the horizon. The phone calls and emails were fast and furious, and there was no middle ground, people thought this was the greatest thing since sliced bread, or it was reengineering in a fresh new package. Some of the System facilities had experienced reengineering in the mid nineties and the sour taste still remained. The calls and emails were answered with an in depth presentation on Six Sigma for the senior leadership at each facility. These presentations had an extremely

positive effect on the attendees. If the original reaction to the concept had been poor, they were now at least interested and thought that this might work. If the initial reaction was positive, they were now true believers and couldn't get their hands on enough books and articles on the topic. In fact, several facility leaders requested the Center (which hadn't been formally established) to come and assist them in a project using Six Sigma techniques. Facilities were informed that the formal rollout and Six Sigma training would take place in early 2002, and that all facilities would have an equal opportunity to be involved. Some facilities persisted with their requests, it was later discovered that compliance with these requests was a potential disaster.

EARLY SUCCESS

The initial project was conducted at the System's Center for Emergency Medical Services (CEMS). As previously stated, CEMS is the largest EMS provider in the Eastern United States. CEMS provides emergency and non-emergency ambulance transport to approximately 40,000 patients annually. CEMS had a chronic problem with their billing department, bills were consistently inaccurate and not sent out in a timely manner. This was seen as "low hanging fruit" and immediately targeted for the first Six Sigma project. A sponsor and a team of content experts were assembled and given a briefing on Six Sigma concepts and methodologies. The team quickly got to work on defining and measuring the process, and contacted the Health System's central finance department for data. Senior EMS administration was kept up to date by frequent report-outs and meetings with the Six Sigma team.

The project had three components: First, the accuracy of bills was addressed to decrease defects and rework. Second, the speed at which data was processed was addressed to decrease the backlog of bills. And third, the cost of overtime to process the data was looked at. Administrators were impressed by the detail of the data and what could be learned from the numbers. For example, at the time the project began, they were looking at transferring a biller out of the department due to her perceived lack of accuracy. Once the numbers were revealed, it was shown that she was one of the most accurate in the department, and that another biller was responsible for over 50% of the total errors made. It was also found that a single biller was far more accurate and faster than the others, responsible for less than 1 % of the total departmental errors. She was brought onto the team to share best practices during the improve phase.

Once the project neared completion, the Chief Financial Officer for the Health System was briefed and asked to confirm the savings. Initially skeptical, he quickly realized and verified that over $275,000 in annualized savings resulted from the project. As word began to spread, the calls and emails increased.

EARLY PITFALLS

As the pressure from system facilities mounted to start new projects, a decision was made to explore this possibility prior to the training of new black belts (which was

scheduled for early 2002). Two facilities were chosen based on the similarity of the requested projects. Both community hospitals were experiencing a chronic problem with bed turn-around times. They felt that the time from when a patient was discharged to the time the bed was available for a new patient was too long and too variable. Sounded like an ideal Six Sigma project. The two Six Sigma trained employees set out to assist these facilities.

In one hospital, the project was being driven by the number two administrator. He had come from the consulting field and was aware of the benefits of Six Sigma. He was chosen as the projects champion/sponsor and assembled the team. After a meeting of the team and a briefing on Six Sigma concepts and methodologies, the team had mixed feelings about the process. The major concern was that the issue being addressed had been a chronic topic and many attempts had been made to resolve it. The attitude of the team was that nothing could solve the problem since they had already tried "everything". Several weeks of data collection took place after the initial meetings. Initially, it was found that a system for data collection needed to be put into place and followed by the employees. After several attempts to persuade the employees to comply with the data collection process, it was decided that the criteria for "complete" data would be lowered (against the advice of the Six Sigma team). The concern was that if the process for reporting data was not followed, what were the chances of the redesigned bed turn-around process being followed. Once the data was analyzed, the causes of the poor compliance became clear.

The data was well received by the facility administrators, and helped them realize the benefits of the detailed measurement employed by Six Sigma teams. As is often found with Six Sigma data, the problem did not lie where they thought. It became clear that the same problems that caused the initial poor data collection were in fact affecting the process being examined. The units that had incomplete data also had poor bed turn-around times, while the units with the more complete data had better times. Since a major regulatory inspection of the facility was drawing near, the decision was made to delay the improve phase until the inspection was over. Just prior to the inspection, the administrators involved with the project briefed the CEO of the facility on its progress. This was the first time the CEO had received a report and had not been exposed to any of the Six Sigma orientation sessions. The CEO examined the data, and felt that the improvements needed could not wait until the regulatory inspection had been completed. Not following the Six Sigma methodology, a group was formed and subsequently put into place a single process change that was thought to be the solution. The Six Sigma team was not involved in the process and found it best to concentrate their efforts elsewhere.

Meanwhile, the same Six Sigma team had been working on a similar process issue at another of the System's community hospitals. This hospital's CEO had a requested the Six Sigma team work with an administrator that was designated as a future black belt. Similar to the project at the first community hospital, this project also dealt with turn around time of hospital beds. The Six Sigma team had an initial meeting with the senior

leaders of the facility to discuss Six Sigma methodologies and a timeline for the project. The CEO and approximately 30 department heads and administrators attended the meeting. Subsequent to the meeting, the CEO expressed concern with the time line, as this was a pressing issue of great importance to the hospital. He was assured that the project would be completed as quickly as possible while adhering to the DMAIC methodology.

It quickly became clear that there was no process in place for gathering the data that would be needed for analysis. A data collection process was devised and data collection began. After the first two weeks of collection, the compliance rate for reporting of times was less than 15%. After a meeting with the CEO, a group was formed to look into the compliance problem. The group was lead by the Six Sigma team and looked at the process that was put in place for reporting of times. It was found that the process for reporting times directly paralleled the process for turning around beds. This was a similar finding to that of the other facility. The group then set out to redesign the reporting process so data could be collected. This redesign was met with some resistance once responsibilities were shifted between departments. There were also labor relations issues that arose due to this shift in responsibilities. It was made clear to all parties that this redesign was made primarily to gather data and that once the group analyzed this data the group as a whole would be designing the new process. This explanation was satisfactory and data collection began once again. After several weeks of additional data collection, it was found that the compliance rate was now between 16 and 45%, and widely variable by hospital unit and time of day. The focus of the project shifted to gaining compliance with process changes. The small process changes put in place to aid in data collection have also assisted in streamlining the original process. The CEO has been fully supportive and is monitoring the progress carefully. The black belt candidate is currently in formal training along with three green belt candidates from the facility, and the project has shifted back to decreasing bed turn-around time.

RESISTANCE

One of the major rules of competition is to never underestimate your opponent. This rule holds true as well for implementing change in organizations. As previously stated, the Health System had (and still has) a System wide quality management program that has been very successful. Initial opposition to even the concept of Six Sigma came from this division. The initial outcry was that the Health System had an established system for improving quality, and that Six Sigma was only successful in the manufacturing industries. The Quality Management division did however make a concerted effort to learn more about the methodology. As they became more familiar with it, Health System staff started to ask about the differences between the current methodology, specifically PDCA, and the DMAIC process. The decision was made to attempt to blur the line between the two methodologies and promote the use of DMAIC for business processes, while PDCA would continue to be used for clinical processes. A decision that, in hind site, proved to be flawed, as one of the first Six Sigma projects within the System turned out to be clinical in nature. This was not planned, however the issue was

so important that it took precedence over our initial decision to limit DMAIC to business processes. It became apparent to most quality management professionals throughout the Health System that the line between DMAIC and PDCA was not blurry as it was presented, but sharp and clear, with most of them realizing on their own the benefits to the statistical rigor and data driven techniques of Six Sigma. This fact forced the reconsideration of the approach to differentiating (or not) the two methodologies. It was decided that DMAIC would be positioned as another tool in the Health System's tool kit, lying next to PDCA, as a hammer sits next to a screwdriver in a technician's toolbox. PDCA would be used for certain issues, while DMAIC would be used where more rigor and statistical analysis may be needed. This is an over simplification as there are many more differentiating factors between the two processes.

As the Quality Management leadership learned of the benefits of Six Sigma, their strategy shifted from their original claims that there was no use for the methodology in healthcare, to attempting to integrate what they felt were the best parts of DMAIC into PDCA. It was continuously reinforced by senior leadership that Six Sigma would be implemented throughout the Health System as a pure methodology and not integrated or merged with any existing process improvement techniques. It was felt that this approach was necessary to reap the full benefits of Six Sigma. The quality management leadership then requested formal training of chosen staff members as Black Belts and Green Belts, a decision which is still pending. Meanwhile, presentations on Six Sigma were being made to various quality management committees at both the hospital and System levels, the distinction between DMAIC and the current methods were now being made clearer. As interest built, a formal rollout was being planned.

FORMAL ROLLOUT

The conclusion was reached that the best way to transform the Health System into a Six Sigma organization was to use John Kotter's eight-step process for creating major change. The process begins with establishing a sense of urgency; this calls for identifying and discussing crises, potential crises, or major opportunities. Senior leadership saw a major opportunity to apply Six Sigma methodology to the relatively untouched field of healthcare. They also felt that making operations more efficient, and subsequent cost savings, could avert a potential crisis due to the recent dramatic changes in the healthcare marketplace. The second of Kotter's steps it to create a guiding coalition. A group was formed with enough power to lead the change effort. This group included the top executives and leaders of the Health System, as well as the individual facilities. Kotter's steps three and four include creating and communicating a vision. A vision was created that tied into the Health System's vision as well as to the System's five-year strategic plan. This vision was then communicated to senior leadership, middle management, and all new employees within the Health System through meetings and seminars. The fifth step is to empower others to act on the vision. The implementation plan for Six Sigma did exactly that, as will be described later in this paper, the plan was to rollout Six Sigma in each of the System's facilities individually, each hospital and ancillary service would choose their own black belts and green belts. The System would

support and lend guidance to these Six Sigma teams with a central division staffed by Master Black Belts that would operate out of the Center for Learning and Innovation. Kotter's Sixth step is to create short term wins. As Six Sigma is rolled out at the individual hospitals six at a time, the System will gain six wins every five months. These short-term wins will build upon each other until the "tipping point" is reached and the benefits of Six Sigma are realized throughout the Health System. Once this point is reached, Kotter's seventh step can be accomplished, consolidating gains and producing still more change. Once the benefits of Six Sigma are appreciated by the masses, the methodology will spread throughout the System and be used to change systems, structures, and policies. New employees will be hired and existing employees will be promoted and developed who can implement the vision and continue the change. Kotter's eighth and final step is realized when the new approaches are anchored in the organizational culture. This will be accomplished when the connection between the new employee behaviors that are attributable to Six Sigma, as well as the Six Sigma successes, are connected to the organizations success. Careful measurement and tracking will be carried out in order to tie Six Sigma to an increase in operational performance.

In order to communicate the vision, a large-scale media event was held on January 16, 2002, at a Manhattan hotel to introduce the Center for Learning and Innovation and the Six Sigma Institute. On hand were the new CEO of the North Shore - Long Island Jewish Health System, Michael Dowling, and the new CEO of General Electric Corporation, Jeffrey Immelt. Many other invited guests joined them, as well as many representatives from the press. Mr. Dowling discussed the importance of bringing the best practices from the business world into healthcare, stating, "Healthcare organizations are facing increasing challenges, if you want to be a leader in this business any more, you've got to be more efficient, more productive, deliver services in an improved way and streamline the processes". Mr. Immelt expressed his pleasure in seeing the practices that had helped G.E. attain their global position implemented in the not-for-profit sector. Mr. Immelt stated that the implementation of such practices "was a bellwether in the industry-setting the stage for the transformation of healthcare delivery". The advantages of using Six Sigma in healthcare were also discussed, as well as the plan to transform the North Shore - Long Island Jewish Health System into a Six Sigma organization. On January 24th and 25th, 2002, the communication effort continued as the top 40 executives from the Health System were taken away to a "corporate boot camp". At this boot camp the senior Health System leadership heard noted speakers such as Dave Ulrich and Steve Kerr speak about the benefits of Six Sigma and how the methodology could help accelerate a sweeping culture change in an organization. Representatives from G.E.'s Leadership Practices Team were also on hand to give an executive overview of Six Sigma and to discuss the implementation of the program throughout the Health System. The System leadership had a chance to hear first hand of the plans for Six Sigma implementation, and of the importance of the program to the future of the Health System. In this way, the Six Sigma implementation would be driven from the top, as this is one of the most important factors for its success.

The decision was made to roll Six Sigma out at six facilities at a time, with a four-wave initial implementation. This decision was based on the theory of the "tipping point", the theory that small successive wins will eventually cause an idea or trend to "tip" and spread rapidly throughout an organization or society. The first six facilities were chosen based on the interest of their CEO's. Various projects were chosen ranging from an Accounts Receivable project to one looking to reduce the amount of pediatric medication errors. A mix of tertiary hospitals, community hospitals, and system services were chosen for the first round so the System could feel the full impact of Six Sigma at all levels. Each facility chose a black belt and three green belt candidates based on information provided to them by the Center. These employees were given an orientation and began formal Define training the first week in March. The first six projects are scheduled to be completed in August, with the second wave of facilities beginning formal training in September. The plan is to have over 60 completed projects by the end of wave 4 (approximately 30 months) with a System wide financial savings in excess of $6 million. The one community hospital project that was under way when training began has been rolled into the first wave.

Current projects include:

* Reduction in Accounts Receivable days and an increase in cash flow

* Increase in the number of O.R. cases and a decrease in O.R. turn-around time

* Decrease in Emergency Room wait time and a decrease in bed turn-around time

* Decrease in cycle time for Nuclear Medicine procedures

* Increase in Emergency Department billing accuracy and efficiency, and a decrease in time to process a bill

* Decrease in medication errors in a Neonatal Intensive Care Unit

LESSONS LEARNED

It has become clear that the published perils and pitfalls of Six Sigma are very true indeed. If Six Sigma is not driven from the top, it is doomed to failure, as was found in the first community hospital project. You will recall that the CEO was not on board from the beginning and did not fully understand the process. The subordinates did not see the CEO as having an active role and therefore did not take the project as seriously as they should have. Since this time, the CEO has taken part in several Six Sigma educational opportunities (including boot camp) and now has requested a new project be initiated.

A major error in judgment was succumbing to the pressure of beginning projects prior to the start of formal training. Although it seemed important at the time to show the value

of Six Sigma and bring it to the masses, the potential failure of the two projects could have soured the System's outlook on the program. This, combined with the assumption that a single black belt could undertake two simultaneous projects, doomed these projects to failure. Although a more experienced black belt may be able to take on this challenge, it should be avoided in the early stages. An inexperienced black belt, and potentially even a seasoned veteran, should be given the time to focus on a single process.

One of the major potential pitfalls that was successfully avoided within the Health System, was the attempt by Quality Management to merge the DMAIC process with their existing PDCA process. It was decided early on to keep Six Sigma pure, although, as previously stated, the initial strategy was to blur the differences between DMAIC and PDCA, this strategy failed due to the obvious similarities and striking differences between the two methodologies. The early attempts to "sell" Six Sigma for business processes only, failed when the benefits of using DMAIC became clear. The strategy was quickly changed and the Six Sigma process was communicated as another tool in the Health System's toolbox, the decision of which tool to use would be based on the specific project at hand.

Another lesson learned from our implementation was to make sure not to use Six Sigma terminology unless the project is actually using the DMAIC process. A potential pitfall was letting the project coordinator at the second community hospital publicize the fact that a Six Sigma project was underway at the facility, while the facility was actually just preparing for the project by attempting to measure a process. Although it was planed to do a full scale DMAIC sequence, early information gathering showed that a uniform process did not actually exist for the question at hand. By assigning the task of measuring the process, administration was quick to realize that the process they thought needed to be improved did not actually exist. Talk about the power of Six Sigma, the experience was eye opening to some in leadership, while others seemed to anticipate the outcome.

CONCLUSION

Six Sigma is a very powerful tool, when implemented correctly it cannot only improve corporate efficiency and the bottom line, but can actually change the culture of an organization. However, careful steps must be taken to rollout the program smartly. You must know your organizations current culture in order to best understand how to implement a Six Sigma program within it. It cannot be emphasized enough that the program must be driven from the top, if it is not, it is doomed to failure. Senior leadership must promote it and support it at every level throughout the organization, making personal appearance to speak about it when possible. It should also be incorporated into the management reporting structure, if scorecards are used it should be a prominent item on them. Early presentations must be simple and show how data is used to drive the changes; the power of data cannot be over emphasized. Finally, over communicate by a factor of 1000, lack of understanding breads fear and anxiety. In this

case study, once the Quality Management division realized the benefits and uses of Six Sigma, they embraced it, and currently plan to send individuals to black belt and green belt training.

In conclusion, Six Sigma can be successfully deployed in any organization, including a large integrated healthcare system. By following the published steps and understanding your corporate culture, the potential perils and pitfalls can be successfully avoided.

ACKNOWLEDGMENTS

David Saleta, Black Belt and team leader for the three early projects

[Reference]REFERENCES

[Reference]Gladwell, M. 2000. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little Brown. Kotter, J. 1995. Why Transformation Efforts Fail. Harvard Business Review. (March -April): 61.

[Author Affiliation]Alan H. Cooper, Ph.D. Asst. Vice President Center for Learning and Innovation North Shore - Long Island Jewish Health System 200 Community Drive Great Neck, NY 11021 [email protected]

How quality improvement programs can affect general hospital performance

Eitan Naveh,  Zvi Stern. International Journal of Health Care Quality Assurance. Bradford: 2005.Vol.18, Iss. 4/5;  pg. 249, 22 pgs

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Subjects: Studies,  Q uality o f service ,  Hospitals,  Health care delivery,  Performance evaluation

Classification Codes 9130   Experiment/theoretical treatment ,  9178   Middle East ,  8320   Health care industry

Locations: Israel

Author(s): Eitan Naveh,  Zvi Stern

Document types: Feature

Publication title: International Journal of Health Care Quality Assurance . Bradford: 2005. Vol. 18, Iss.

Source type: Periodical

ISSN/ISBN: 09526862

ProQuest document ID: 915115851

Text Word Count 5932

Document URL: http://80-proquest.umi.com.ezproxy.mnl.umkc.edu/pqdlink?did=915115851&sid=15&Fmt=2&clientId=45248&RQT=309&VName=PQD

Abstract (Document Summary)

Given the enormous size of the health care industry, the problem of developing high-quality, cost-effective health care delivery systems is growing in importance. There is general consensus that health care systems require a continuous process of quality improvement (QI). Less agreement, however, surrounds the mechanisms to be implemented so that such a process is effective. This study aims to bring empirical evidence to support the hypothesis that a QI program in a general hospital - a special context of the health care delivery system - does not necessarily lead to better overall organizational performance results. The study was done at the hospital level, and included all acute care hospitals in Israel. Data was collected in 16 of the country's 23 hospitals, a 70 percent response rate. The study compared hospital performance before and after the QI program implementation. The study shows that QI creates meaningful improvement events. In addition, the research supports the hypothesis that increasing the number of QI activities (items) included in the QI program brings about more improvement events. The results do not support the hypothesis that high, rather than low, intensive implementation of QI activities leads to more improvement events. The special context of general hospitals decreases the effects of a QI program on overall hospital performance, whereas QI activities function as triggers in initiating improvement events.

Title: Lean and six sigma: Not for amateurs - First in a 2-part series Author(s): Jacobson JM, Johnson ME Source: LABMEDICINE 37 (2): 78-83 FEB 2006 Document Type: Editorial Material Language: English

Cited References: 45       Times Cited: 0       

KeyWords Plus: ACUTE MYOCARDIAL-INFARCTION; HEALTH-CARE; MANAGED CARE; MEDICAL-CARE; QUALITY; IMPROVEMENT; OUTCOMES Addresses: Jacobson JM (reprint author), Six Sigma Black Belt & Net Educ Design Inc, Kennedale, TX 76060 USASix Sigma Black Belt & Net Educ Design Inc, Kennedale, TX 76060 USAGeorge Grp Lean Six Sigma Courses, Commerce, TX USATexas A&M Univ, Commerce, TX USA Publisher: AMER SOC CLINICAL PATHOLOGY, 2100 W HARRISON ST, CHICAGO, IL 60612 USA IDS Number: 006RF ISSN: 0007-5027

Title: GUM and six sigma approaches positioned as deterministic tools in quality target engineering Author(s): van Merode F, Molema H, Goldschmidt H Source: ACCREDITATION AND QUALITY ASSURANCE 10 (1-2): 32-36 DEC 2004 Document Type: Article Language: English

Cited References: 12       Times Cited: 0        Abstract: In order to improve the quality and logistics of care, health care organizations should deal with uncertainty of demand and supply, inflexibility of the health care organization and its capacity and organizational complexity. What is needed is integrated process management and standardization to improve quality and safety of care, patient logistics and working conditions of staff. This paper tries to fuse (and in that way better understand) the concept of six sigma with the guide to the expression of uncertainty in measurement in relation to the concept of target engineering. Author Keywords: quality models; critical control points; error rate Addresses: van Merode F (reprint author), Univ Maastricht, POB 616, Maastricht, NL-6200 NetherlandsUniv Maastricht, Maastricht, NL-6200 NetherlandsTilburg DCT, Reg Diagnost Serv Ctr, Tilburg, NL-5048 NetherlandsDeltaBouman Inst, DeltaLab, Poortugaal, NL-3170 Netherlands E-mail Addresses: [email protected] Publisher: SPRINGER, 233 SPRING STREET, NEW YORK, NY 10013 USA Subject Category: CHEMISTRY, ANALYTICAL; INSTRUMENTS & INSTRUMENTATION IDS Number: 876VJ ISSN: 0949-1775

Title: Pathology and patient safety: the critical role of pathology reduction and informatics in error quality initiatives Author(s): Becich MJ, Gilbertson JR, Gupta D, Patel A, Grzybicki DM, Raab SS Source: CLINICS IN LABORATORY MEDICINE 24 (4): 913-+ DEC 2004 Document Type: Article

Language: English

Cited References: 78       Times Cited: 1         Abstract: Pathology is entering a new era where it will need to mobilize new resources to face the challenges posed by the Institute of Medicine's (IOM) and Rand Corporation's call to arms for patient safety [1,2]. In 1999 the IOM reported in "To Err is Human: Building a Safer Health System" [1] that the medical community was responsible for many serious errors in the delivery of care. The focus of the report was on "system" errors, and it was very weak in its dealings with diagnostic errors. However, the report, in a very pointed way, implicated the lack of clear-cut clinical documentation and the lack of standards (both in vocabularies and in common data elements) as key factors in many errors. The report has had a broad impact on health care delivery and patient safety research. A review of the implications of the IOM report for pathology by Sirota [3] in 2000 lays the foundation for the central thesis of this article. It is the authors' goal to describe how pathology informatics can play a critical role in the detection, prevention, and correction of errors.

Just as the IOM report has been a call to arms, so a report by the Rand Corporation [2] in 2002 on the delivery of care in over 20 urban centers has caused great concern to the public and health care providers. This report estimated that nearly half of the patients treated for a variety of diseases had actually met the approved standards of care. Of particular importance in this report was the frequent citation of laboratory testing as a central issue in improper care delivery. Unsurprisingly, it was not improper test ordering that was at the top of the error list for diagnostic interpretation, but lack of adequate testing as the primary laboratory concern.

These are two landmark articles that every pathologist should read and digest thoroughly, because they have great implications for our future practice. Given the relative novelty of patient safety and health care research in pathology, this article serves to provide an overview of important developments in pathology and informatics as they relate to patient safety and error reduction initiatives. The authors strongly believe that patient safety in pathology is inextricably linked to cost-effective and "waste-free" or "lean" management practice methodologies. Lean management principles, Six Sigma, and quality improvement are crucial to achieving our goal of error-free delivery of care in pathology.

KeyWords Plus: CONSENSUS STATEMENT 1999; SURGICAL PATHOLOGY; PROGNOSTIC-FACTORS; MEDICAL ERROR; COLORECTAL-CARCINOMA; ANATOMIC PATHOLOGY; NATIONAL DATABASE; DIAGNOSTIC ERROR; UPDATED PROTOCOL; Q-PROBES Addresses: Becich MJ (reprint author), Univ Pittsburgh, Sch Med, Dept Pathol, Ctr Pathol Informat, 5150 Ctr Ave,UPMC Canc Pavil,3rd Floor, Pittsburgh, PA 15232 USAUniv Pittsburgh, Sch Med, Dept Pathol, Ctr Pathol Informat, Pittsburgh, PA 15232 USA E-mail Addresses: [email protected] Publisher: W B SAUNDERS CO, INDEPENDENCE SQUARE WEST CURTIS CENTER, STE 300, PHILADELPHIA, PA 19106-3399 USA Subject Category: MEDICAL LABORATORY TECHNOLOGY

IDS Number: 881NM ISSN: 0272-2712

Title: Six sigma implementation - Hurdles and more hurdles Author(s): Gijo EV, Rao TS Source: TOTAL QUALITY MANAGEMENT & BUSINESS EXCELLENCE 16 (6): 721-725 AUG 2005 Document Type: Article Language: English

Cited References: 5       Times Cited: 0        Abstract: Six Sigma implementation is spreading to many organizations the world over and success stories are increasing every day. In several cases, impressive financial benefits have been recorded, whereas in a few organizations, the implementation of this methodology has not given the expected benefits. In this article, the authors discuss various hurdles faced by the organizations from their experiences, and give a few recommendations for Six Sigma implementation. Author Keywords: six sigma; black belt; green belt; master black belt; project selection; critical to quality ( CTQ); sigma level Addresses: Gijo EV (reprint author), Indian Stat Inst, SQC & OR Unit, 8th Mile,Mysore Rd, Bangalore, Karnataka 560059 IndiaIndian Stat Inst, SQC & OR Unit, Bangalore, Karnataka 560059 India E-mail Addresses: [email protected] Publisher: ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 4 PARK SQUARE, MILTON PARK, ABINGDON OX14 4RN, OXFORDSHIRE, ENGLAND Subject Category: MANAGEMENT IDS Number: 966YK ISSN: 1478-3371

Title: Hospital laboratory survival in a cost control environment Author(s): Kiechle FL Source: JOURNAL OF CLINICAL LIGAND ASSAY 24 (4): 235-238 WIN 2001 Document Type: Article Language: English

Cited References: 52       Times Cited: 0        Abstract: Change is continuous. Therefore, one does not manage change, but rather one must continuously manage through change. The clinical laboratory, like healthcare in general, has been subjected to reduced reimbursement and operating budgets, and demands for greater efficiency. Methods to reduce the operating costs and increase efficiency in the laboratory include the introduction of robotics and automation, near patient testing, and a different mix of skill levels in the workforce. Methods designed to reduce the cost per procedure include increasing test volume through hospital laboratory mergers, consolidation or integration, and development of outreach programs which market laboratory services to physician offices, nursing homes and other hospitals. These strategies have individual strengths and weaknesses and have been used with varying

degrees of success by a variety of healthcare providers. The successful implementation of any of these survival strategies requires identification of the barriers hospital culture may present, development of methods to overcome these barriers, and appropriate management of transformation for employees. The vigilant evaluation of emerging technologies and design of laboratory space and workflow is the task of all laboratorians. Author Keywords: near patient testing; outreach program; change transformation; barriers to change; laboratory automation; six sigma; ISO 9000 KeyWords Plus: HEALTH SYSTEM; QUALITY; AUTOMATION; CARE; POINT; PERFORMANCE; NETWORKS; MODEL; JAPAN Addresses: Kiechle FL (reprint author), William Beaumont Hosp, Dept Clin Pathol, 3601 W 13 Mile Rd, Royal Oak, MI 48073 USAWilliam Beaumont Hosp, Dept Clin Pathol, Royal Oak, MI 48073 USA Publisher: CLINICAL LIGAND ASSAY SOC, 3139 S WAYNE RD, WAYNE, MI 48184 USA Subject Category: BIOCHEMICAL RESEARCH METHODS; IMMUNOLOGY; MEDICAL LABORATORY TECHNOLOGY IDS Number: 603GA ISSN: 1081-1672

Title: Widening the Six Sigma concept: An approach to improve organizational learning Author(s): Wiklund H, Wiklund PS Source: TOTAL QUALITY MANAGEMENT 13 (2): 233-239 MAR 2002 Document Type: Article Language: English

Cited References: 28       Times Cited: 2         Abstract: Six Sigma has been established as an approach to improving organizational performance, and many manufacturing companies have reported on their successive work with Six Sigma programmes. Often, the focus of Six Sigma is put on only reducing defects and improving process capability. This paper discusses Six Sigma as a company-wide approach for organizational improvement incorporating organizational learning. Six Sigma programmes have been studied and the fundamental principles of organizational learning have been applied in order to improve the long-term implementation of the programmes. The paper also discusses factors associated with manufacturing work organization and leadership that are essential for improving organizational learning and for stimulating the competence development and motivation among personnel. Addresses: Wiklund H (reprint author), Mid Sweden Univ, Ostersund, S-83125 SwedenMid Sweden Univ, Ostersund, S-83125 SwedenLulea Univ Technol, Lulea, S-97187 Sweden Publisher: ROUTLEDGE, CUSTOMER SERVICES DEPT, RANKINE RD, BASINGSTOKE, HANTS RG24 8PR, ENGLAND Subject Category: MANAGEMENT IDS Number: 510JM ISSN: 0954-4127

Title: Implementation of a PACS using six sigma methodology Author(s): Sigal RC, Dessales-Martin D, Ruelle C, Kouchit N, Guillemot M, Klipfel B Source: RADIOLOGY 221: 527-527 Suppl. S, NOV 2001 Document Type: Meeting Abstract Language: English Cited References: 0      Times Cited: 1       Publisher: RADIOLOGICAL SOC NORTH AMERICA, 820 JORIE BLVD, OAK BROOK, IL 60523 USA Subject Category: RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING IDS Number: 491UC ISSN: 0033-8419

Title: Designing an integrated extracorporeal therapy service quality system Author(s): Riley JB, Justison GA, Povrzenic D, Zabetakis PA Source: THERAPEUTIC APHERESIS 6 (4): 282-287 AUG 2002 Document Type: Article Language: English

Cited References: 18       Times Cited: 0        Abstract: Reorganization in clinical operations of a national service provider organization, Fresenius Medical Care Extracorporeal Alliance (FMC-EA), provided the opportunity to overhaul and integrate quality systems. Under the new structure, the management of acute dialysis, apheresis, open-heart perfusion, and intraoperative autotransfusion services were combined into an integrated service portfolio supported by a multidisciplinary team of nurses, perfusionists, and technicians. This communication is intended to be a concise review of the literature that establishes the foundation for the new quality system as well as a discussion of the five clinical policies and clinical procedure guidelines that govern clinical behavior in mobile, point of care, acute extracorporeal therapy services. The clinical policy standards are based on recognized essentials and guidelines published by professional organizations, federal and state government agencies, and accreditation groups. The standards list the essential behaviors that clinicians should exhibit during the provision of extracorporeal therapy procedures such as acute therapeutic apheresis. Compliance with the redesigned procedure guidelines and policies will provide the clinical practice platform for continuous quality improvement (CQI) activities, benchmarking, and self-improvement. These practices can lead to improvements in the quality of care, a decrease in medical errors, and a reduction in overall health care costs. Author Keywords: clinical policy; continuous quality improvement; extracorporeal therapy; process improvement; procedure guidelines; quality assurance; six sigma Addresses: Riley JB (reprint author), Fresenius Med Care Extracorporeal Alliance, 16818 Via Campo Court, San Diego, CA 92127 USAFresenius Med Care Extracorporeal Alliance, San Diego, CA 92127 USAMidw Univ, Cardiovasc Sci Program, Coll Hlth Sci, Glendale, AZ USA Publisher: BLACKWELL PUBLISHING INC, 350 MAIN ST, MALDEN, MA 02148 USA Subject Category: HEMATOLOGY

IDS Number: 582WH ISSN: 1091-6660

1. Frankel HL, Crede WB, Topal JE, et al.Use of corporate six sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 201 (3): 349-358 SEP 2005 Times Cited: 0

2. Berlitz FA, Haussen MLSix Sigma in clinical laboratory: Comparison of two automated chemistry systems CLINICAL CHEMISTRY 51: A80-A80 Suppl. 6 2005 Times Cited: 0

3. Becich MJ, Gilbertson JR, Gupta D, et al.Pathology and patient safety: the critical role of pathology reduction and informatics in error quality initiatives CLINICS IN LABORATORY MEDICINE 24 (4): 913+ DEC 2004 Times Cited: 1

4. Kazmierczak SCLaboratory quality control: Using patient data to assess analytical performance CLINICAL CHEMISTRY AND LABORATORY MEDICINE 41 (5): 617-627 MAY 2003 Times Cited: 3

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