Six Sigma In Healthcare

Six Sigma In Healthcare
By Trevor Coons Brigham Young University Marriott Business School

What Will Be Covered Six Sigma defined in context of healthcare
Brainstorming Exercises Nuts and Bolts How It Works Real World Examples Exercises Summary Reading List There will be lots of notes for every slide, if an explanation is not satisfactory look up the associated articles for clarification. As a manager it is important that you recognize your role as a leader for change. Leaders in Healthcare need to build relationships and increase collaborative efforts in their industry. Leaders “need to provide an environment for innovation that allows for new and more flexible roles and responsibilities for healthcare workers.” From: “Crossing the Quality Chasm- A new healthcare system for the 21st century”. Institute of medicine. National Academy Press. Washington D.C page 138 Admittedly “Crossing the Quality Chasm” is not about Six Sigma nor will you find it in the index, however it is a great source for managers in Healthcare who are serious about improving quality.

Six Sigma Defined In Context of Healthcare
Statistically Sigma or σ is a character used in statistics to represent standard deviation. Six Sigma denote a process that is so in control that only 3.4 parts are defective for every million produced. There is a lot of in-dept math but using a simple equation and the following table a manager can get a feel for how good their process is doing. Computing: Defects per million opportunities (DPMO)= (Defects/ (Opportunities X Total units) ) X 1,000,000 Defect: is characteristic that you define as unacceptable. Opportunities: how many times each unit has at failing. Total units: numbers of all units produced in the time frame. After you have DPMO you can look it up on the table. σ DPMO 1 : 691,462 2 : 308,538 3 : 66,807 4 : 6,210 5 : 233 6 : 3.4 Equation from: “Faster Turnaround Time”. Martocci, Maude, and Pellicone, Angelo. Quality Progress. March 2006: 33 ( Table adapted from:“Factors critical to the success of Six-Sigma quality program in an Australian hospital”. Hilton, Roger and Balla, Margaret and Sohal, Amrik S. Total Quality Management. Vol. 19, No. 9, September

As A Tool With Six Sigma Motorola company was able to Eliminate waste Improve quality Reduce cost Reduce lead time Six sigma has its roots with famous companies such as GE and Motorola who began using it during the 1980’s. The key point to point to Six Sigma with regard to manufacturing is to “fabricate products that are so good that virtually no defective products are created”. Reducing variation in the process leads to fewer defects. Motorola really took Six Sigma to heart and greatly improved its processes. From: “Application of the Six Sigma concept in clinical laboratories: a review”, Gras, Jeremie M. and Philippe, Marianne. Clin Chem Lab Med. 46: pages

Coming To Healthcare Quality improvement plan Controlling variance is essential Increases accountability Builds off of current processes Quality of care has become an increasingly more important metric. Because the care the industry produces continues to vary, Six Sigma has grown to play a larger role. Six Sigma is a comprehensive management tool whose success has led to selective adoption in the healthcare field. “Six sigma, as a quality improvement plan, uses data analysis and other problem solving techniques to evaluate the ability of a process to perform defect free, where a defect is anything that results in customer dissatisfaction.” The importance of controlling and limiting variance in healthcare is compounded by the fact that failure to do so could led to misdiagnosis, malpractice suits and even death. Additionally one aspect that adds to the appeal of Six Sigma is that of its potential to increase accountability. Accountability coupled with the timely recognition and resolution of errors increases the desire of managers to implement a Six Sigma program. Adapted from: “Addressing Variation in Hospital Quality: Is Six Sigma the Answer?”. Woodard, Tanisha D. Journal of Healthcare Management. 50:4 July/August pages226,232,234 It can be difficult to comply with all the numerous quality initiatives, however it can be possible to tweak them and “piggyback Six Sigma onto current total quality management efforts so that minimal disruption occurs in the organization” (Revere and Black,377). There are many pressures in healthcare to improve quality. Two of the more formidable proponents are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Medicare (Woodard, 227). Yet, it has been suggested that “Six Sigma is an extension of Failure Modes and Effects Analysis required by… JCAHO”. So in essence, many healthcare organizations are already taking strides toward Six Sigma and simply may not realize it (Hilton, Balla and Sohal, 891). From: “Integrating Six Sigma with Total Quality Management: A Case Example for Measuring Medication Errors”. Revere, Lee and Black, Ken. Journal of Healthcare Management. 48:6 November/December “Addressing Variation in Hospital Quality: Is Six Sigma the Answer?”. Woodard, Tanisha D. Journal of Healthcare Management. 50:4 July/August page 227 “Factors critical to the success of Six-Sigma quality program in an Australian hospital”. Hilton, Roger and Balla, Margaret and Sohal, Amrik S. Total Quality Management. Vol. 19, No. 9, September page 891

Brainstorming Exercises
How could Six Sigma help? First, come up with ideas how Six Sigma could improve healthcare as a whole Next ,think about how Six Sigma principals could help your company Lastly, think of ways that being able to create strong measures could help you in your job In manufacturing it is possible to eliminate nearly all “human variability”. Automation makes it possible by allowing for the detailed measurement of assignable causes of variation. “In Healthcare, however, the delivery of care is largely a human process, and the causes of variability are often more subtle and difficult to quantify.” 2:3 This fact doesn’t however need to deter the healthcare industry from attempting to improve. For the longest time a doctor’s success in helping an expectant mother deliver a baby was measured mostly by whether or not the mother and child lived thru the ordeal. Medical science had been making advances that improved outcomes, but the fact remained that the death rate for the procedure was extremely high. Then in the 1930’s Virginia Apgar invented what obstetricians know today as the Apgar Score. It was a point system that assed the health of the baby (Ex. Two points for vigorous breathing, two points for moving all its limbs). This measurement system has played a role in saving countless thousands of people. So it is clear that to improve quality the healthcare profession doesn't need excuses but rather ingenious innovators who are willing to take a unique look at the world. Virginia believed she knew a better way to perform the birthing procedure but was in a position that “had no authority to challenge the conventions” of her day, so she innovated her own approach. To create change she devised a score. Gawande, Atul. “Better- A Surgeon’s Notes on Performance.” New York: Henry Holt and Company, 2007 Six Sigma could help the healthcare industry deal with its over utilization and insufficient capacity, by creating measures that reduce waste, improve outcomes and decrease the cost of poor quality. Healthcare costs can be categorized into three groups: process costs, costs of quality and costs of poor quality (which make up 67%, 13% and 20% respectively). Aggressive Six Sigma programs can help to redesign processes to limit the costs of poor quality while improving the patient experience, thus helping to recover some of the costs of poor quality. From: “Lean-Six Sigma – Tools for rapid cycle cost reduction”. Caldwell, Chip. Healthcare Financial Management Association. October Practicing Six Sigma can help nearly all companies improve their customer service, and help them improve their bottom line with cost savings and increased utilization from improving turnover times. As a manager/administrator you should be able to help your subordinates see the prospect that Six Sigma holds for them but the next slides give some job specific examples.

Brainstorming Exercises
How could Six Sigma help? Scenario 1 You are the manager over Lab and Imaging You seem to be plagued by complaints about taking too long Scenario 2 You are an Emergency Department Manger A slue of seemingly indeterminable delays are frequently putting you on diversion First, this is a common scenario and most managers with sufficient funding will add the FTE’s necessary to solve their own quality problems. However, this usually passes on the bottlenecks and throughput issues to somebody else, resulting in little to no improvement in patient care. With Six Sigma a manager would be able to recognize these issues and be able to have all the information necessary to make the best decision for the patient and the company. From: “Lean-Six Sigma – Tools for rapid cycle cost reduction”. Caldwell, Chip. Healthcare Financial Management Association. October page 2. North Shore University Hospital was in a similar situation. They used Six Sigma to better define and measure their total turnaround time (TAT). Doing so allowed them to analyze the process steps that needed improvement and they were able to cut more than half of their the time off their TAT and as well as decreasing the standard deviation (time variance) in half as well. From: “Faster Turnaround Time”. Martocci, Maude, and Pellicone, Angelo. Quality Progress. March 2006: (

All or Nothing vs. Contingency
Nuts and Bolts All or Nothing vs. Contingency All or Nothing means that the company either fully commits to Six Sigma or else it shouldn’t bother - It offers greater rewards - But it comes at the cost of greater risk Contingency Allows a company to tailor its’ own solutions If done half-hazard, it can cause more harm than good The case for All or Nothing: Too many companies trying to implement Six Sigma get frustrated by the heavy commitments and then quickly drop it and say it was a failure. The general problem was not that Six Sigma couldn’t do anything for them but rather that it was implemented wrong (whether people weren’t properly trained or there wasn’t a sufficient resource commitment or any number of other factors). The major point is that companies like Motorola, GE and Allied Signal (and many others) experience greater levels of success with customer service and global profitability. From: “Application of the Six Sigma concept in clinical laboratories: a review”, Gras, Jeremie M. and Philippe, Marianne. Clin Chem Lab Med. 46: Likely the difference between these benchmark companies and the ones that don’t succeed lies in them not having a real champion for the cause but rather a fad manager. The case for Contingency: As a methodology for process and quality improvement Six sigma has demonstrated great flexibility in being able to adapt to nearly any process. Success is not limited to a specific demographic of hospital. “Six Sigma has taken root in a wide variety of settings: within individual departments, throughout small and rural hospitals and within large teaching facilities and across multihospital systems.” 2-10 From: “Healthcare’s Horizon- Form Incremental Improvement to Designing for the Future”. Stahl, Richard and Schultz, Bradley and Prexton, Carolyn. Six Sigma Forum Magazine February 2003.page 26. If viewed as a methodology, Six Sigma is a really versatile tool that can be implemented at any level. Some believe you can’t use and apply the various aspects of Six Sigma separately. Goodman and Theuerkauf have a very different opinion, “According to many proponents, if you are going to do Six Sigma rightly, you will undergo an all encompassing change and embrace a business improvement process made up of very separate and distinct tools and methodologies, most of which existed prior to the Six Sigma craze.” They go on to contradict proponents who argue for the whole “enchilada”, by saying that the enchilada is made up of lots of parts and if Six Sigma proponents argue that there aren’t other dishes to be made with the ingredients, they report “nothing could be farther from the truth”. From: “What’s Wrong with Six Sigma?”. Goodman, John and Theuerkauf, Jon. Quality Progress. January Page 38 In summary both methods have their upsides and downsides. One way to test the waters for a company to see if it is at a point where Six Sigma can help is for the company to do a pilot. If a manager or even an employee feels their company could benefit from Six Sigma they should research the topic in-depth and implement the principals as best as they can (with careful notice being paid to keeping track of results). These measures will likely help encourage administrators to better understand how Six Sigma can help the company. From: “Addressing Variation in Hospital Quality: Is Six Sigma the Answer?”. Woodard, Tanisha D. Journal of Healthcare Management. 50:4 July/August page 235

Nuts and Bolts All or Nothing
Six Sigma Organization Champion Works with Black belts Appropriates resources Black belt Heavily trained Full time job cost savings Green belt Basic training Part time and work in groups According to Foster: Six Sigma can cost a company a great deal to train for but “expected returns from Six Sigma projects can run into the hundreds of thousand of dollars” (401). Even though these large returns can be a major draw for management, they create a great deal of pressure on the Six Sigma program to achieve generous yields. The slide and its notes are information that has been adapted from Foster, S. Thomas. “Managing Quality-Integrating the Supply Chain” 4th edition. New York: Prentice Hall, 2010:

Organization- Champion Works with the black belts Meets frequently with Black belts Identifies potential Black belts to train Appropriates scarce resources They have to balance internal and external concerns Has final say on major projects and process changes According to Foster: A Champion is usually someone with power in the company. In a large company, it might be a vice president. He works in concert with the Black belts to spot potential projects. He also stays in tune with what the green belts are up to and tries to identify talent for any future Black belt training. They have to allocate resources in what they perceive to be the most advantageous way. They not only have to balance concerns from customers but those of employees. It is almost vital to the success of the Six Sigma program that they be a high ranking person in the company because the decisions they make have to be done in the context of the company’s financial and strategic position. The slide and its notes are information that has been adapted from Foster, S. Thomas. “Managing Quality-Integrating the Supply Chain” 4th edition. New York: Prentice Hall, 2010:

Organization- Black belts Heavily trained Costs thousands of dollars and several month to train Is a specialist in quality management tools Full time job cost savings Key to Six Sigma Projects vary in duration and scope Black belt training at Villanova University (online) costs $6,995 and takes over two months (see course offerings at . According to Foster: “The Black belt is the key to Lean-Six Sigma” (402). They are key because of the wide variety of tools they are equipped with. Champions can’t be dedicated to Six Sigma projects full-time and green belts likely can’t take on as profound of projects. Black belts are what make Six Sigma possible in many if not all companies. Black belt training lasts about 4 months and generally costs somewhere between $10,000 and $20,000. They are specifically trained individuals who works on cost saving projects full-time. They have projects that run anywhere from two months to a year (depending on the project’s scope). Another unique cost savings role Black belts can take on is becoming a Master Black belt. These are highly experienced Black belts capable of training other Black belts for the company. This allows training to be brought into the company and can thus reduce training costs. The slide and most of its notes are information that has been adapted from Foster, S. Thomas. “Managing Quality-Integrating the Supply Chain” 4th edition. New York: Prentice Hall, 2010:

Organization- Green belts Basic training Trained in basic quality tools Part time and often work in groups Depending on the company They can do Black belt work Or green belts can be relegated lower priority projects Green belt training at Villanova University (online) costs $1,980 and takes over two months (see course offerings at . According to Foster: Green belts have a basic knowledge of Quality tools. They work on quality projects part-time and can do Black belt work or Green belts can be relegated lower priority projects. “In a small company of 100 employees, there might be 1 black belt and 60 green belts (402)”. Some organizations even have yellow belts and they are just employees who are familiar with process improvement tools. The slide and most of its notes are information that has been adapted from Foster, S. Thomas. “Managing Quality-Integrating the Supply Chain” 4th edition. New York: Prentice Hall, 2010:

Six Sigma Process DMAIC Define Scope of the project Critical-to-quality factors Measure Create performance baseline Collect comparable data Analyze Use data to identify underlying problem Improve Implement process that will correct the problem Control Monitor process To best understand each of these steps, we’ll follow a case example of North Shore University Hospital as they apply these steps. (The bullets in blue.) The Six Sigma process can be summed up in these five steps and the implementation of these steps within the framework of the Six Sigma organization. In literature it is common to see the five steps shorted to DMAIC. There is also frequent reference to forming a DMAIC team or following the DMAIC process. It is either a team that follows these steps or the process of implementing them. This slide and all the Process- DMAIC’s slides with much of their accompanying notes were adapted from Wooard, Tanisha D. “Addressing Variation in Hospital Quality: Is Six Sigma the Answer?” Journal of Healthcare Management. 50:5 July-Aug. 2005: and Martocci, Maude, and Pellicone, Angelo. “Faster Turnaround Time”. Quality Progress. March 2006: ( Unless it has been specified otherwise.

Process-DMAIC Define In specific terms explain what's wrong Critical-to-quality factors ED and PACU are diversion, Total Turnaround Time (TAT) taking too long, created a high-level process map Measure Create baseline Collect data Target TAT set to 120 min. and upper specification limit set to 150 min., defect defined as a TAT over 150 min., collected information on 195 patients Define: In traditional Six Sigma it is necessary to have quantitative data to perform the DMAIC steps. In regard to Healthcare this can be difficult considering the service nature of the industry and the high variation that comes with it. While certain qualitative factors may go into a project, if you can’t attach a numeric value to the process you want to improve, you’ll likely get frustrated and fail. But if you feel the projects’ undertaking is too critical to quality to pass up or ignore, you can do what Virginia Apgar did (as mentioned in the notes of slide number six), and create your own metric or “score”. Make sure the metric is based off of intuitive and relevant factors that can objectively be measured. In defining the purpose of the project a clear scope can be set thus laying the ground work for a successful project. Like the old adage says, “A problem well defined is half solved.” Be sure to focus on causes and not consequences. Measure: First one should find something to measure that will increase your understanding of process outcomes. This steps’ purpose is to show the errors and successes on the same plane to be able to compare them to see what is going on. A caution: don’t waste time measuring things that aren’t critical to quality. Unless you can tie it to quality, it is likely you shouldn’t be measuring it. The last significant and important function of measurements is that they help document what happed before you took steps to improve (this verifies if your plan worked). North Shore Community Hospital (NSUH) - Define and Measure The hospital had been struggling with slow turnover times in the PACU and ED leading to having to go on diversion and causing great customer and physician dissatisfaction. They formed a DMAIC team to solve the problem. The DMAIC team created a process map that outlined the steps between when a patient was discharged and when the admission RN was notified that the room was clean/ready. They determined the admission RN’s were their primary customer and in consultation with them the team set the target TAT to 120 minutes and upper specification limit set to 150 minutes (as with many of the applications of Six Sigma in Healthcare, there was no need to set a lower spec limit considering the fact that the faster most of the services are performed the better). The team then measured 195 TAT and calculated that the defective TAT per million opportunities would likely be 672,725.

Process-DMAIC Analyze Use data to identify underlying problem Created a Control Impact Matrix, performed hypothesis testing on what they could control, found the underling problem was employees lacked proficiency with the hospitals bed tracking system (BTS). Improve Implement process that will correct the problem Improved communication within the staff by: documenting communication and reformatting admission RN’s beepers. Retraining employees on BTS and providing laminated instructions cards Analyze: You use the data you’ve collected to compare defective and non-defective units. This is done in an attempt to distinguish the independent variables from the dependent. Upon understanding the cause and effect relationships it will be easier to recognize sources of variation. The human element in Healthcare may introduce most of the variation to some of the processes that get measured, but by recognizing it, steps can be taken to improve. Improve: In this step, managers work on changing and altering processes to fail-safe* them (or in this instance defect-safe them). This is a significant step. Several solutions may have to be experimented with before the answer to the problem is found. Some sound advice: many times in quality highly trained individuals overlook a great resource for problem solving ideas, namely, front line employees. In many ways it is human nature to try and figure out how to do one’s job more effectively (or how to do less work). Front line employees can offer insights that can’t come from simply observing them. NSUH- Analyze and Improve The independent variables that impacted the process were identified. The DMAIC team targeted several factors for statistic analysis. The control impact matrix allowed the team to see which of the variables they had control over and which ones they didn’t. They then sorted these into high, medium and low impact categories (impact on customer experience that is). They then began to perform statistical analysis of the high impact variables that they had control over. (Analysis included an analysis of variance and a two sample t-test.) They ruled out several variables, then finally found that the source of the variance was in the operation of the BTS system. They then took steps to correct the situation by improving communication within the staff by documenting communication and reformatting admission RN’s beepers (to allow for quicker notification of a clean and ready room). They then retrained the employees on BTS and providing laminated bedside cards with BTS instructions. *Fail-safe: is to design a process to make errors impossible or at least very unlikely.

Process-DMAIC Control Monitoring the process TAT continued to be monitored on a monthly basis Results Went from a slightly over one sigma process to a 3.1 sigma process Cut standard deviation from 170 minutes to 48 minutes The average TAT went from 226 minutes to 69 minutes Control: By continuing to measure you’ll better be able to confirm that the improvement step went correctly. Monitoring the process can best be achieved by continual measurement and using statistical quality control charts can come in handy (further instructions on how to maintain control of a process can be found on the freequality.org web page under training then at the bottom under the Heading: Statistical Quality Control). It may be advisable at this stage to readjust specification goals and limits to continue to motivate staff to strive for improvement. Most people in Healthcare are familiar with the term “best practice”, which is when you feel you have improved your process as much as possible and it is time to share your experience with other departments at your work to see if they can glean improvements from your process changes. Overall, keep measuring and looking for other projects to apply the DMAIC process to. NSUH- Control A monthly individual and a moving range chart were used to continue to monitor TAT and the improvement continued. The project went on to serve as a pilot for the rest of the hospital and plans were made to improve patient satisfaction scores in other areas. Like it mentioned in the slide, the overall results for the project were very encouraging. The process went from slightly over one sigma process to a 3.1 sigma process. They were able to cut standard deviation in the process from 170 minutes to 48 minutes. Lastly, the average TAT went from 226 minutes to 69 minutes.

Nuts and Bolts Contingency
Advice for Implementing on Contingency Manage expectations Manage for the correct outcomes Pick manageable problems Engage the customer Measure the right thing The slide and its accompanying notes are adapted from the following article: “What’s Wrong with Six Sigma?”. Goodman, John and Theuerkauf, Jon. Quality Progress. January pages As far as a Six Sigma Contingency plan goes, people want the same results of a well carried out and monetarily supported plan, without the heavy investment in training. Likely one of the most excluded aspects of attempts at a Six Sigma process is a properly trained Black belt (but they were dubbed as being “key” in an earlier slide). This slide provides some advice to those who still want to implement Six Sigma without Black belts. (Is that really Six Sigma?… Academically speaking, no, but by following the DMAIC process companies can still enjoy some benefits of Six Sigma). Before explaining the advice, it is important to reiterate that it is necessary to follow the DMAIC process. Manage Expectations: Don’t simply tell employees that the company is going to implement a Six Sigma process and leave it at that. Six Sigma invokes ideas and concepts to people that you may not want them to expect. (Anyone who knows anything about it will begin to think of various statistical tools and Black belts and the like.) Determine whether your assets are tangible and otherwise will be sufficient to reach your desired results. Then set realistic and measurable goals. Then create your definition of success. Share this information with your employees so you’ll give them a clear vision of your expectations. Manage for the correct outcomes: Goodman and Theuerkauf recommend that managers begin with the end in mind and try to find out what results are desired/likely for financial, customer satisfactions /loyalty, internal processes, innovation , employee talent, and learning. Pick manageable problems: Trying to solve overly complex problems without a trained Six Sigma Black belt can be like trying to inflate a car tire with a bicycle pump. Even if you get air in it, it still won’t run like it should. This is the reasoning behind this bullet of advice. You may need to hire or train some people, but you can’t make a screw go in correctly with a hammer. Similarly, you can’t solve certain process problems without some statistical know how. Bottom line, pick doable problems or if it really needs to be solved then get someone trained to do it. Engage the customer: Six Sigma is about improving processes, making them save time and money, etc. However, if you don’t have a great customer feedback system, then how can you know if you did the right project? Difficulty getting feedback is a common problem that causes companies to select the wrong projects, negatively affects customer loyalty, and/or limits project focus (causing a company to not capitalize on opportunities). It is vital to get feedback from your customer (however you choose to do it). Measure the right thing: It is easy for companies to get discouraged trying to implement Six Sigma processes on their own. Goodman and Theuerkauf advise that in measuring financial impacts of process improvements, not only to measure cost savings but increased revenue due to increased customer satisfaction. They also suggest to measure impact within the department that the process change takes place in, and to not set too short of a time frame for measuring process impacts.

How It Works Project types Patient Satisfaction Safety Efficiency
Outcomes Many Others There are many projects that a manager can perform using Six Sigma principals. Patient Satisfaction: In Healthcare most the time (if not all) people aren’t really happy to be in the hospital. It is a rough hoe to row to delight customers. A project example that might fall under this heading is room service. There is an increasing trend in hospitals to offer room service, and Six Sigma could be used by a company to verify the viability and importance of offering it in a hospital that currently doesn’t. Safety: Safety should be pretty self explanatory, it would be any and all projects preformed to enhance patient safety. The Committee on Quality of Health Care in America, suggests taking into account five principals for improving patient safety. 1. Provide leadership- Make patient safety a top priority and make it everyone’s responsibility. 2.Respect human limits in design processes- avoid reliance on vigilance and memory. 3. Promote effective team functioning- people who must work together should be trained together. 4. Anticipate the unexpected- be proactive and design for recovery from errors. 5. Create a learning environment- ensure no reprisals for reporting errors. ( ) An example of this could be preventing medication errors, or patient falls. From: “To Err is Human- Building a Safer Health System”. Institute of Medicine. National Academy Press. Washington D.C. 2000 Efficiency: Doing more with less, eliminating waste, taking out unnecessary redundancy. One example could be improving turnover times in an ED. Outcomes: Projects that improve processes to allow for quicker healing, or decrease the percent of reoccurrences. Example: Testing a protocol to see if it improves clinical outcomes. Many Others: These were just some general ideas for projects but managers can find projects that incorporate all these project types or are more unique in nature.

Performance Variables
How It Works Performance Variables Patient Satisfaction Service Level Service Cost Clinical Excellence Slide and its notes adapted from: “Healthcare’s Horizon- Form Incremental Improvement to Designing for the Future”. Stahl, Richard and Schultz, Bradley and Prexton, Carolyn. Six Sigma Forum Magazine February 2003.pages Performance variables can vary greatly but these four should likely be considered in most Healthcare projects. The main drive behind variable selection is to translate things that customers perceive as essential to quality into process specifications. Patient Satisfaction: can be verified through customer feedback mechanisms. The analysis of this variable can include survey responses and focus groups. (Also managers can and should consider Physician and employee satisfaction because they influence patient satisfaction.) Service Level: this variable should be defined with help from the customer; to see what they consider the varying levels of service to be. Then a capability analysis can be preformed to see what changes can be made to the steps of care that are encompassed in the larger project (ex. Triage, Assessment, Treatment est.). Service Cost: being able to itemize and understand the average cost per procedure; and calculating employee productivity. This is accomplished through financial analysis. Clinical Excellence: is researching outcomes to ensure the effectiveness of processes and procedures. Return rate can be measured along with measuring how long it takes to administer critical care in emergencies and a host of other variables that management can get help identifying working in collaboration with medical staff.

How It Works Physician Engagement Why it is essential
Why so hard to get Think differently Increases burdens How to gain Slide and its notes adapted from: “Engaging Physicians in Lean Six Sigma”. Caldwell, Chip. and Brexler, Jim and Gillem, Tom. Quality Progress. November Why essential: As every good manager in healthcare knows, building good relationships is vital at every level to creating success. This is especially so when undertaking Six Sigma improvements. Caldwell, Brexter and Gillem explain, “Only a handful of process changes can be fully optimized without physician engagement, and active management of the role of physicians may be one of the most vital tasks of senior leaders” (42). Why so hard to get: Physicians are often biased to think using more resources produce the best outcomes and are often inclined to think careful analysis is unproductive - Think differently: Doctors often don’t understand systems thinking, or process improvement. They take a stance that savings need to go to benefit them before the hospital. Physician's are trained to give directions, so it is hard for them to work in a team with people they view as subordinates. -Increases burdens: Process changes can add to the already heavy load of doctors. Many times they have no vested interests in saving the hospital money. Often times what can mean better processes for the hospital can increase complexity for physician’s practice. How to gain: Educate the physicians so they can understand why changes are being made. Seek to build trust, to decrease the combative element between administrators and doctors. Seek win-win project where both can benefit, and when not possible provide a quid pro quo allowing for concessions to be made to the physician for cooperation or consider other incentives. Leverage physician influencers to lead changes (ex. credible doctors or trusted medical staff) instead of hospital leadership.

Real World Examples Organization Project Outcome Achievement
Charleston Area Medical Center Supply chain for surgical supplies Lower inventory, Improved supplier relations Saved: $163,410 immediately $841,540 future Commonwealth Health Corporation Radiology Decreased time between dictation and signature, Improved wait times and staff scheduling $800,000 savings, 25% better throughput and eliminated 14 positions Froedtert Memorial Lutheran Hospital ICU lab times Reduced turnaround times Cut turnaround times from 52 to 23 minutes Mount Carmel Hospital Medicare+ Choice Plan reimbursement Redefined coding working-aged Medicare recipients Profit $857,000 Wellmark Inc. Physician addition to managed care network Reduced time for adding physicians to medical plan Savings: $3 million per year Scottsdale Healthcare Over crowded ED Improved transfer time from ED to inpatient hospital bed Profits: $600,000 Slightly altered table adapted from “Integrating Six Sigma with Total Quality Management: A Case Example for Measuring Medication Errors”. Revere, Lee and Black, Ken. Journal of Healthcare Management. 48:6 November/December

Exercises You are trying to figure out what Sigma level your at
You take meticulous notes of what’s going on in your unit and observe 195 turnovers 130 of those observations were defects Calculate defects per million opportunities (DPMO) (Hint) (Defects/ (Opportunities* Occurrences) ) X 1,000,000 Sigma DPMO 1 691,462 2 308,538 3 66,807 4 6,210 5 233 6 3.4 Answer: (130/1*195) X 1,000,000= 672,725 DPMO Which gives you a process that is pretty much 1 sigma… lots of room for improvement. Equation from: “Faster Turnaround Time”. Martocci, Maude, and Pellicone, Angelo. Quality Progress. March 2006: 33 (

Activities to use in your meeting
Exercises Activities to use in your meeting Managers go on a quality waste walk Discuss training you’d like to pursue in your company Work to reduce reliance on competitive data for improvement initiatives Discuss how to improve physician engagement Waste Walk: Walk around you facility with each of the managers and make a note of: potential plans to improve and future projects ideas. Then return to the meeting and have everyone share and discuss ideas. Training: Discuss the degree to which you’d like to implement Six Sigma and what training would be necessary to achieve that goal. Reduce Reliance: While not all improvements should be initiated in a reactive manner to what competition is doing. Many of the best companies benchmark against themselves to improve. Discuss how you feel your company could implement Six Sigma to improve you company on its own. Ideas from: “Lean-Six Sigma – Tools for rapid cycle cost reduction”. Caldwell, Chip. Healthcare Financial Management Association. October Physicians: Are really important discuss the role you see them playing in future projects. Idea from: “Engaging Physicians in Lean Six Sigma”. Caldwell, Chip. and Brexler, Jim and Gillem, Tom. Quality Progress. November

Summary Six Sigma defined in context of healthcare
Brainstorming Exercises Nuts and Bolts How It Works Real World Examples Exercises Six Sigma defined in context of healthcare: Review main points emphasizing the importance of reducing variation. Brainstorming Exercises: Recap some of your groups ideas for applying Six Sigma Nuts and Bolts: Briefly pass over the Organization and DMAIC process of Six Sigma How it Works: Project types, Performance variables and Physician’s role Real World Examples: remind group of how companies have had great savings and earnings from projects Exercises: reiterate what was learned from exercises Conclusion: Six Sigma is a great tool for healthcare companies to improve the quality of patient experiences and the clinical outcomes they receive.

Reading List “Crossing the Quality Chasm- A new healthcare system for the 21st century”. Institute of medicine. National Academy Press. Washington D.C. 2001 “To Err is Human- Building a Safer Health System”. Institute of medicine. National Academy Press. Washington D.C. 2000 Gawande, Atul. “Better- A Surgeon’s Notes on Performance.” New York: Henry Holt and Company, 2007 “Addressing Variation in Hospital Quality: Is Six Sigma the Answer?”. Woodard, Tanisha D. Journal of Healthcare Management. 50:4 July/August “Healthcare’s Horizon- Form Incremental Improvement to Designing for the Future”. Stahl, Richard and Schultz, Bradley and Prexton, Carolyn. Six Sigma Forum Magazine February “Lean-Six Sigma – Tools for rapid cycle cost reduction”. Caldwell, Chip. Healthcare Financial Management Association. October

Reading List “Factors critical to the success of Six-Sigma quality program in an Australian hospital”. Hilton, Roger and Balla, Margaret and Sohal, Amrik S. Total Quality Management. Vol. 19, No. 9, September “Engaging Physicians in Lean Six Sigma”. Caldwell, Chip. and Brexler, Jim and Gillem, Tom. Quality Progress. November “Faster Turnaround Time”. Martocci, Maude, and Pellicone, Angelo. Quality Progress. March 2006: ( “Integrating Six Sigma with Total Quality Management: A Case Example for Measuring Medication Errors”. Revere, Lee and Black, Ken. Journal of Healthcare Management. 48:6 November/December “What’s Wrong with Six Sigma?”. Goodman, John and Theuerkauf, Jon. Quality Progress. January “Application of the Six Sigma concept in clinical laboratories: a review”, Gras, Jeremie M. and Philippe, Marianne. Clin Chem Lab Med. 46: “Managing Quality-Integrating the Supply Chain”. Foster, S. Thomas. 4th edition. New York: Prentice Hall, 2010.

Six Sigma In Healthcare

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