Before exploring the various ways Six Sigma is currently being used, we should set the stage and understand the challenging environment where this methodology is being put to the test, a relatively small, but growing segment of the health care industry.
Health care today is a vast web of complexity and contradiction. It offers astounding advances in technology and treatment, but is overburdened by inefficiencies, errors, resource constraints and other issues that threaten the accessibility and safety of patient care. A quote from an article published in Health Affairs not long ago summed up the current predicament:
"The medical error rates described in recent national studies are the groans of a collapsing paradigm: the traditional model that an individual practitioner's accumulated personal experience and judgment are the pinnacle of medical effectiveness. Embedded in our culture is the notion of 'finding a good doctor,' when what we really should be looking for is a 'good health care system' that is greater than the sum of its parts and acts on a knowledge base of accumulated best evidence -that can change quickly and continuously if necessary."...
By: Daniel R. Masys in: "Effects of Current and Future Information Technologies on the Health Care Workforce: Health Care Professionals Are Assuming the Role of 'Tech Support' in Explaining Medical Terms to Internet-Savvy Patient-Consumers" Health Affairs, September-October 2002, Vol. 21, No. 5, p. 33-41.
Defining and Eliminating Errors
Errors and variability can undermine the delivery of safe, effective patient care. Six Sigma seems to be an approach that is well suited to addressing disparities and helping to create a "good health care system," since it is designed to reduce variation and defects within a process including the many processes surrounding patient care.
In terms of impact to the patient, a defect in the delivery of health care can range from relatively minor, such as food on a tray that doesn't match the doctor's orders, to significant, such as operating on the wrong limb. In a worst-case scenario, the defect can be fatal, as when a medication error results in the patient's death.
Whether accompanying a family member down the sometimes long road to recovery, or as patients ourselves, many of us feel the impact of failures or process defects. This occurs despite technological and medical advancements and the presence of knowledgeable and dedicated clinicians.
Recent reports from the Institute of Medicine define errors as: "the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning)."
The American Hospital Association cites a number of common medication errors, which are frequently cited as problems within hospitals:
- incomplete patient information (e.g., not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results);
- unavailable drug information such as lack of up-to-date warnings;
- miscommunication of drug orders as a result of poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metrics and other dosing units, and inappropriate abbreviations;
- lack of appropriate labeling as a drug is prepared and repackaged into smaller units; and
- environmental factors, such as lighting, heat, noise, and interruptions that distract health professionals from their medical tasks.
Defining and Promoting Quality
Now that we've defined errors in health care, at least in general terms, how will we define quality? While the term "quality" can take on many definitions based on various perspectives, most clinicians have come to embrace the definition offered by the Institute of Medicine: "Quality is the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Institute of Medicine 1990).
Achieving this goal is not easy. The health care industry has tried a number of methods to raise quality and reduce costs. Over the years, health care providers have adopted reengineering, TQM, CQI, SPC, PICOs, PDSA and a host of other quality programs designed to solve the quality puzzle. Although some gains were made along the way, there were noticeable gaps and improvements were largely unsustainable. Lower cost and higher quality are not always considered compatible objectives. We are learning that in many cases, raising the level of quality can eliminate the need for rework, which in health care often translates to higher readmission rates.
Why would Six Sigma produce better results than other initiatives? It turns out there are a number of factors in its favor. Six Sigma is a very rigorous and highly disciplined process based on statistical tools and techniques designed to identify and eliminate defects in a process. While some quality programs incorporate statistics there are some key differences, a few of which are noted in the table below.
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Changing Human Behavior
Physicians are often receptive to the idea of Six Sigma because it is an evidence-based, scientific approach to problem solving. But it is important to keep in mind that while statistical tools will be very effective in identifying root causes of variation, they only address half the equation.
In many cases, when we speak of transforming the health care system we're not just talking about moving data points on a chart; we're really talking about changing human behavior. Success requires supporting the statistical methodology with change management and facilitation techniques. Without addressing the acceptance, or "A" side of the equation, hospitals and health care systems will find they have a harder time leading this change.
Hospitals have some unique challenges in this regard. Generally, physicians are independent and do not work for the hospital, so gaining their acceptance may require a different approach. Experience has shown they are often more likely to comply with change initiatives if shown valid data that proves a benefit to the way they work, their patients' satisfaction and outcomes, and a correlation between higher quality and lower cost. This is where Six Sigma and related change management techniques prove extremely effective.
In any organization, employees have their own ideas about why a particular process is less than optimal. The statistical analysis drawn from Six Sigma may validate those theories or point to hidden factors that were not considered. The benefits of statistical analysis are illustrated in one example where a clinical project, conducted at an academic medical center, focused on lowering the rate of hospital-acquired bloodstream infections. The issue represented a quality and cost concern since nationwide, preventable hospital acquired infections annually claim between 20,000 and 60,000 lives, and result in up to $18 billion in unnecessary expenditures.
In the beginning, everyone on the hospital team thought they had the right answer as to why ICU bloodstream infections were higher than CDC recommendations. Six Sigma tools and techniques helped point the team in the right direction and allowed the hospital to reach levels that were better than the national guidelines. Without clear-cut data and analysis and a process for implementing sustainable change, infection rates at the facility would probably still be high for lack of a valid way to build consensus and create new standard operating procedures.
Summary
A variety of healthcare organizations, from small rural facilities to multi-hospital systems, have completed similar Six Sigma projects tackling a host of clinical and operational issues. We're only seeing the tip of the iceberg in terms of the potential for transformation within the health care industry that applying Six Sigma and change management methods can bring. Early adopters such as Commonwealth Health Corporation in Kentucky and Virtua Health in New Jersey, have pioneered the way becoming self-sufficient and demonstrating that the system works over time.
Whether Six Sigma is used to improve existing processes (DMAIC) or to create entirely new processes, services, systems and structures (DFSS), the methodologies have proven valuable for health care providers of every size and scope. Enthusiasm must be tempered with realism, however. There is still no magic pill that allows you to shed those unwanted pounds overnight without diet or exercise, and there is no magic "quick fix " to the problems plaguing the health care industry. Systemic change will require widespread commitment and ongoing attention to the most critical drivers impacting cost, quality and productivity. The benefits to adopting Six Sigma are worth the effort since all of us stand to gain from a safer, more efficient and cost-effective health care system.
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