Demonstrating clear alignment between Six Sigma projects and a healthcare organization’s strategic imperatives, vision or mission has been an elusive exercise for many organizations.

Judging from a random sampling of web sites and hospital lobbies, most mission statements represent variations on a theme and relate to common issues such as clinical quality, cost management, service excellence and valuing individual contributions. But do these organizations know – based on reliable data and analysis – how they are really doing in fulfilling their mission? Chances are, they do not – unless they have been able to translate it into actionable metrics and specific behaviors. Six Sigma represents one aspect of a management framework that can help to decipher and validate the vision.

Moving From Tweaking to Transforming

While results can certainly be seen on a project-by-project basis, transformation takes place only when projects are aligned with overall goals and when the organization has been able to develop a real performance culture. Combining technical and cultural strategies is key; and it is important to build early success through projects that can produce an immediate and meaningful impact.

By acquiring skills and experience, the health system can then build internal capability to deliver benefits on an ongoing basis. Sustaining this momentum and taking the initiative to an even higher level requires strengthening management and leadership systems through operating mechanisms and performance reviews that link individual efforts to the organization’s “big Ys,” or the desired overall results.

When viewed as a management initiative, Six Sigma represents breakthrough innovation, a systematic approach linked to business goals and a way to connect people with processes. It can serve as a platform for selecting and developing leaders, a format to pursue and measure the right projects, and a strategy to achieve measurable long-term financial and quality results. Obviously, it also is a set of rigorous methods and tools that allow you to focus on specific processes – eliminating defects and reducing variation.

But the most successful organizations realize it is not just about statistical tools or training. To achieve alignment, it is important to look at Six Sigma in a broader context, including elements such as:

  • Organizational design: Are improvement efforts spread across the entire organization?
  • Staffing: Are sufficient resources been dedicated and are the “best and brightest” being selected to lead initiatives?
  • Development: Are options being provided for continuing education, experiential or project-based training and cross-functional capabilities?
  • Measurement and accountability: Are projects supported by the right metrics and aligned with strategic objectives?
  • Rewards/recognition: Is there a process for celebrating success and are rewards linked to key metrics?
  • Communication: Is there a detailed plan in place (who, what, when) to provide clear and consistent communication at all levels of the organization?
  • Information Technology: Are there sufficient software programs or IT solutions in place for project funnel management, financial linkage and monitoring results?

The Big Ys in Healthcare

While there may be differences in the way they are described, the major objectives of quality healthcare generally are focused on a handful of basic areas. They are:

  • Clinical excellence or outcomes
  • Patient safety
  • Quality service that leads to high patient satisfaction
  • Good working conditions that keep physicians, nurses and staff happy, and reduce turnover
  • Sufficient operating margin to support the hospital’s mission
  • Living up to commitments to the surrounding community

Change does not happen at this 30,000-foot level, however, so an organization needs to begin to break down each Big Y objective into the various processes and sub-processes underneath. And then identify and concentrate on the drivers that produce most of the results or cause the majority of defects.

Using perioperative services as an example, the table below illustrates one way to translate high-level goals into specific metrics and solutions. In this case, the Big Ys for the department are quality, capacity and net revenue.

Perioperative Service Needs

Core Business Metrics

Quality <> Capacity <> Net Revenue


First Case Start Time

Room Turnover Time

Room Utilization

Patient Safety


  • Pre-op delays
  • Surgeon not available
  • Anesthesia not available
  • Equipment/supplies not available
  • Staff roles
  • Setup/cleanup process
  • Communications
  • Block time allocation/utilization
  • Case time allocation
  • Add-on management
  • Scheduling guidelines
  • Anesthesia time
  • Right side
  • Instrument counts


  • Lean pre-op process
  • Staffing/anesthesia time
  • Preference cards
  • Equipment replenishment
  • Work-out: work process, Roles, Responsibilities, Commuications
  • Kaizen event: TAT
  • Level loading blocks/casesacross days/time by clinical service
  • Match schedule to staffing
  • New guidelines: add-ons
  • Process for identifying, reporting, taking corrective action

Through a combination of Lean, Six Sigma and change management techniques, these broader areas can be broken into key performance metrics, and then further delineated into underlying critical factors and potential solutions. For instance, if the goal is to improve start time for the first surgery of the day, the organization might look at factors such as delays in the pre-op area, or resource issues. Solutions might include the use of Lean techniques to simplify the pre-op process and a Six Sigma project targeting staffing or anesthesia time. With education and experience, every area or issue within the organization can be analyzed in this way, determining which factors drive the primary goals and which tools or solutions are most appropriate.

Learning from Barriers and Best Practices

Not all Six Sigma initiatives are created equal – or implemented successfully. But lessons can be learned from failure as well as triumph. Some of the factors that have characterized less-successful Six Sigma deployments are lack of leadership support, poor communication, inadequate training and mentoring, projects not clearly defined, and neglect of the cultural side of change. Effectively managing people, processes and information also can present challenges within the healthcare environment. The industry generally lags behind others in using data in the most meaningful ways. But that is understandable. With lives on the line, healthcare employees tend to create work-arounds to temporarily fix a problem. With a problem masked, little attention may be paid to finding its root cause and solving the problem at that level.

North Shore-Long Island Jewish Health System implemented Six Sigma several years ago and has achieved impressive results integrating this approach with other proven strategies as part of its Center for Learning and Innovation. According to Alan Cooper, vice president of the North Shore health system, strategic alignment is something the organization continually reviews and refines. “We are coordinating Six Sigma projects directly with our chief operating officers to be used strategically at their sites. One of the COOs is currently tackling a project to improve the revenue cycle as part of operational performance aligned with their core measures.”

Efforts to align Six Sigma with organizational strategies also are working for the Nebraska Medical Center. Since implementing Six Sigma and change management, CEO Glenn Fosdick reports that patient care has improved, physician satisfaction scores have gone up, and nursing turnover dropped from 14.5 to 11.9 percent last year.

“We always have more work to do,” said Fosdick, “but we have a lot more clarity and we’re getting people to understand the word ‘accountability.’ Everyone has a clear idea of what is important and what is expected. But I believe the number one issue is that leadership has to believe in this stuff. If the CEO isn’t pushing it, I’m not sure how successful it will be.”

As part of their Six Sigma initiative, the Nebraska Medical Center uses a balanced scorecard program that is provided to the board on a monthly basis. They have been implementing this at the service line level and will soon be using it at the departmental level as well. In nursing, for example, they might track metrics such as length of stay, budget performance, physician satisfaction, patient satisfaction and nursing turnover.

The ‘Big Why’

With Six Sigma, there is a tendency sometimes to get caught up in the tools, the training, the certification, the statistics…but the really “Big Why” behind any improvement initiative in healthcare is the ability to deliver better care and service for patients. There are numerous examples to show how this approach can be translated into results that have a positive impact on the patients coming through the system everyday, and for the professionals caring for those patients.

Effectively translating the organizational vision or mission into specific metrics is crucial to creating organizational alignment and driving performance across the enterprise. Frequent and ongoing communication will help to ensure that everyone knows how his or her job connects back to the overall goals – whether they work in nursing, housekeeping, the pharmacy or any other area.

Since every organization has certain distinct requirements and readiness factors, it is impossible to write a generic and universal prescription for adapting and aligning Six Sigma. However, every organization can learn from the best practices of others while customizing an approach that will fit within its culture and priorities.

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