Concerns about the quality of healthcare in the United States have escalated during the past decade. The failure of effective and efficient processes within healthcare has led to an unsafe environment, staggering numbers of medical errors (by omission and commission), and countless near misses. As healthcare and the system that delivers healthcare have become more complex, the opportunities for errors abound.

The 1999 report of the Institute of Medicine, “To Err Is Human: Building a Safer Health System,” represented a clear challenge to physicians and other medical providers to improve the American healthcare system. The Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations are now publishing hospital quality data on public web sites. The next step in this effort will be public reporting on physician outcomes along with an increase in paying for quality, or pay-for-performance contracting.

Correcting the healthcare system will require a concentrated effort by physicians. There is a need to break down the traditional boundaries that separate physicians, hospital administrators and non-physician clinicians by shifting away from a culture of blame, and working together to systematically design safer, more effective and efficient systems.

Quality and the Quest at Florida Hospital

The Institute of Medicine defines quality as “the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Process measures are valid quality measures when their relationship to important health outcomes has been proven. For instance, “Door to antibiotic time in pneumonia patients within four hours” improves survival and is linked to many hospital departments and their processes (emergency department, radiology, laboratory, physician and pharmacy).

About Florida Hospital

  • The Florida Hospital system is the busiest system in the United States. It has more than one million patient visits each year.
  • It is an acute-care healthcare system.
  • It has 3,025 beds throughout central Florida.
  • It has 13 Centra Care walk-in urgent care centers.
  • It is part of the comprehensive network of 17 hospitals of the Adventist Health System, Florida Division.
  • Florida Hospital has been recognized as one of “America’s Best Hospitals” for the last six years by U.S. News & World Report.

For healthcare outcomes to become valid quality measures, they must be related conclusively to a process or a group of processes that can be modified to improve the outcome, according to Mark R. Chassin, M.D., author of Is Health Care Ready for Six Sigma Quality?

Florida Hospital is embarking on the ambitious journey to achieve the highest levels of excellence. To remain competitive and fulfill its mission, the organization has begun to pilot Six Sigma as well as additional tools and approaches to support more effective process improvement. It hopes to achieve greater speed and quality at a reduced cost – critical since the healthcare dollar paid to all providers has decreased, the cost of providing care is higher and the cost of technology is exponentially increasing. Florida Hospital’s goal is to become a highly reliable performing organization prior to its centennial in 2008.

The Meaning of Six Sigma Goals

The sigma in Six Sigma signifies the quality of variation in a process, or the number of defects in a process. An organization that performs at Six Sigma quality has 3.4 defects (customer dissatisfaction occurrences) per million opportunities (DPMO). Most U.S. businesses operate at a level of two to three sigma. That means between 308,530 and 66,807 defects per million customer contacts. In healthcare, customers include patients, physicians and administrators.

In general, hospitals operate at a level of three sigma or below. But many hospitals and health systems are becoming Six Sigma-savvy. Mount Sinai in New York City, New-York-Presbyterian, Yale-New Haven Hospital and Stanford Medical Center are just a few examples. The answer to why healthcare is moving to adopt Six Sigma quality standards is based on the simplest Six Sigma concept: outcomes of any process are the result of what goes into the process. In other words, Y = f(x1, x2, x3….). In order to improve process outcomes, healthcare professionals must distinguish between the trivial and critical drivers of processes.

Physicians feel the variations – not the averages – in a process. A process is a series of steps and activities that take inputs (such as an order for a CT scan) provided by suppliers (physicians), creating outputs (CT scan report availability to physician) and adding value (decrease time from order to availability) for the physician. It is the purpose of Six Sigma to reduce the variation, create more predictability, meet customer expectations and reduce costs.

Relying on the Scientific Method

Six Sigma heavily relies on the scientific method (developing a hypothesis, analyzing objectives, designing experiments) to study processes and outcomes. The Six Sigma methodology includes the following steps, named by the acronym, DMAIC:

  • Define – Define the problem (Y = dependent variable, clarify and relate to the customer).
  • Measure – Measure the target metric and confirm that the measurement system is accurate.
  • Analyze – Use statistics to find root causes and generate a prioritized listing of them (x = independent variables).
  • Improve – Determine and confirm the optimal solution.
  • Control – Create a plan to sustain the improvement.
Florida Hospital’s First Six Sigma Initiatives
Order to Results
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Door to Treatment
Cardiac Catherization Lab (Cath. Lab)
Intracardiac Electrophysiology Study (EPS)

Medication Delivery/Dispensing Errors
Coronary Artery Bypass Graft (CABG)
without Cath.
Bloodstream Infections
Urinary Tract Infections
Resistanet Organisms
Blood Utilization

The average length of time to study, develop a plan and improve a process ranges from 3 to 12 months depending on project scope and goals. Successful projects require cross-functional (e.g. physician, emergency department nurses, radiology managers, transporters, laboratory technicians) work teams. Often the physician is called upon for his/her subject matter expertise to provide clarity and define his or her own needs.

Since improving the quality of a process alone is not enough to create an excellent outcome, Florida Hospital’s consultant, GE Healthcare, uses the following formula:

Quality (Q) x Acceptance (A) = Effectiveness (E)

Simply stated, the effectiveness of the result is equal to the quality of the solution times the acceptance of the idea.

Concluding Thoughts

An ineffective plan occurs if a team improves a process, but the healthcare team is not willing to accept the plan. Often, keeping an average process the same and improving the healthcare acceptance will be more effective than changing a process.

If physicians participate on teams, communicate their needs and help design improvement strategies, it is more likely that their concepts will become an integral part of the improvement plans. Physicians should not act as innocent bystanders in process improvement but must actively participate and support teams in performing the hard work that goes along with it.

There is a national call for urgent action to improve healthcare quality with a secondary benefit of reduced cost. Arguably, the greatest improvement in quality can only be achieved through professional activity in the hospital and office.

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