What is clear is that Six Sigma can drive bigger improvements in patient care and cost reduction, and potentially, do it faster. In the handful of hospitals that have successfully implemented Six Sigma, the results are impressive. Hard financial savings in the hundreds of thousands of dollars range per Six Sigma project have been reported. However, what is much less clear from these early successes is how to implement Six Sigma in healthcare provider organizations without excessive pain. More specifically, can more healthcare providers take on Six Sigma without alienating workforces; disenfranchising quality improvement staffs; and, without busting the budget.
Picture this: A meeting of the senior staff at a regional hospital after attending an industry conference on healthcare quality improvement.
COO, Administrative Services…”There seemed to be a lot of attention around Six Sigma at the conference. The results being reported are impressive. Maybe we should consider launching a Six Sigma initiative. What do you think?”
Director of Patient Care…”I’m all for getting a bigger return on our CQI (Continuous Quality Improvement) initiative, but I’m worried about the time commitment. Where will these full time Black Belts that Six Sigma relies on come from? We’re short staffed as it is!!”
Director of Engineering Services…”I’ve had a number of Quality Action Teams launched in my department since we started CQI. For the commitment, I haven’t seen the return. If Six Sigma will get us some concrete cost savings, I’ll support it. But I wonder if it’s overkill.”
Manager, CQI…”I’d be crazy to say no to anything that will improve our CQI effort. But, I’m very skeptical about our ability to take on any new quality tools or programs. The fact is we have trouble today getting consistent participation on our CQI councils and Quality Action Teams. It feels like Six Sigma is a solution to the symptom, not a response to the root causes of our CQI problems.”
COO, Administrative Services…”I appreciate everyone’s concerns and will admit that we’re in no position to spend a million dollars. But I’d sure like to tell our Board that we aren’t sitting here with our heads in the sand on CQI.”
The Six Sigma “Crossroads” for Healthcare Providers
The fictional conversation described above is in fact taking place more and more often in the executive offices of many healthcare providers. The debate about Six Sigma is a critical one, because the stakes are high – both in risk and return.
What is clear is that Six Sigma can drive bigger improvements in patient care and cost reduction, and potentially, do it faster. In the handful of hospitals that have successfully implemented Six Sigma, the results are impressive. Hard financial savings in the hundreds of thousands of dollars range per Six Sigma project have been reported. However, what is much less clear from these early successes is how to implement Six Sigma in healthcare provider organizations without excessive pain. More specifically, can more healthcare providers take on Six Sigma without alienating workforces; disenfranchising quality improvement staffs; and, without busting the budget?
The Case For Six Sigma in Healthcare
The case for adopting Six Sigma in healthcare organizations has more to do with managing the politics and power of quality improvement than applying advanced statistical problem solving tools. For example, in the few hospitals that have successfully deployed Six Sigma, the biggest benefit has been the adoption by the CEO of quality improvement as a strategy for institutional survival.
Healthcare organizations are inherently complex with numerous stakeholder groups pushing their own interests. The result is often a state of constant contention. Physicians, nurses, administrators, regulators and customer advocacy groups all want better quality, but rarely agree on how best to change.
Six Sigma, with its insistence on top executive commitment and a dedicated Black Belt infrastructure, can cut through the fog of power and politics in healthcare organizations. The adoption of Six Sigma creates an immediate demand to deploy Black Belts to work on projects worthy of their investment cost. Quality problems formerly stuck in lower level quality teams are suddenly elevated to a faster track.
Six Sigma’s use of statistical tools such as regression analysis and hypothesis testing, whether necessary to finding the solution or not, adds authority to final recommendations. That is very comforting in environments with high risk factors and life threatening situations.
Finally, the adoption of a universal standard of quality measurement – defects per million opportunities – provides a powerful tool for creating a culture of shared accountability for improvement. Six Sigma measurement forces the development of common definitions of what constitutes an error.
In an environment in which there is a tremendous incentive to deny blame or at least rationalize errors, a common scorecard for measuring quality is a huge step forward. Six Sigma’s brilliantly simple approach of measuring all performance on common standards is a tremendous force for driving consensus on healthcare performance requirements and for understanding which errors can be better controlled.
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The Hidden Barriers
Six Sigma is not without pitfalls. In our experience, there are several barriers lurking below the surface for healthcare organizations considering its deployment.
First is the price tag. The typical Six Sigma Deployment package calls for a significant commitment in executive education and employee orientation, as well as investment in a cadré of intensively trained Black and Green Belts – all in advance of any realized benefits. For example, consultant proposals typically start at $500,000 for Six Sigma Deployment in a mid-sized hospital – and that’s usually just in the first year!
Under cost pressures, most hospital CEOs are not prepared to go to battle with boards or medical staffs to make the Six Sigma case. The decision to commit to a conventional Six Sigma Deployment is a high-risk decision for embattled healthcare executives.
While the start-up costs alone of Six Sigma Deployment are daunting, the challenges in actually implementing the Six Sigma discipline are perhaps even more formidable. There are at least three unique conditions in healthcare organizations that can make Six Sigma Deployment slow going at best.
First is the absence of, or difficulty in getting, baseline data on process performance. Hospitals, clinics, long-term care facilities and the like are characterized by thousands of processes, sub-routines and communications. In the typical environment, it is not unlikely that two to three or variations will exist in routine processes from shift to shift. While lots of data is captured, it is often not the right information, nor in a form that lends itself to the statistical quality analysis of Six Sigma.
The result is long project ramp-up times (typically six months or more) to gather the requisite data for application of Six Sigma tools. This condition, coupled with the shortage of personnel available to fill Black Belt and even Green Belt positions, produces long project cycle times beyond even the typical 6 to 9 month average reported by commercial users. Long project completion cycles also limit the number of problems that can be addressed.
The second condition that severely impacts the velocity and long-term sustainability of Six Sigma Deployment in healthcare organizations are the longstanding functional walls and professional group silos. While parallels may exist in business, the inherent tensions among physician groups, nurses, support staff, and administrators are typically more deeply ingrained and emotionally laden.
This cultural condition presents a significant obstacle to Six Sigma Deployment, particularly when it comes to tackling core processes that cut across the organization and affect the practices of multiple groups. Just getting consensus on problem definition can be a Herculean task. As one hospital Black Belt, working on a project to improve thru-put in the Radiology Department’s CT scan process, confided, “I sometimes feel like I am trying to get consensus in the Tower of Babel. Everyone is on a different floor, speaking a different language and driving a different agenda.”
Functionalism and “at-odds” factions within healthcare organizations often push Six Sigma Deployment toward fixing the less contentious, “lower-touch” processes such as billing accuracy and collections. To be sure, these are important problems to fix. But without the ability to confront patient care and patient flow processes, Six Sigma in healthcare runs the risk of being marginalized.
Not to be forgotten among the barriers to Six Sigma Deployment in healthcare organizations is the psychology of the workforce. While the corporate business community struggles with deterioration of employee loyalty and commitment in the wake of accounting scandals and relentless downsizing, healthcare providers still attract employees who are passionate about their work.
Surveys by healthcare industry associations validate that the majority of healthcare employees feel their work is important and believe they could do more to improve the quality of patient care. That’s the good news. The bad news, according to the surveys, is that healthcare employees don’t believe their employers fully appreciate them or offer enough opportunities for them to directly participate in quality improvement.
Unfortunately Six Sigma Deployment can reinforce this potential workforce ambivalence towards quality improvement. By design, Six Sigma focuses on developing a relatively small cadré of improvement experts. It is not a game played by the masses due to cost and time restraints. Regardless of efforts to involve employees, healthcare organizations deploying Six Sigma will face a backlash from employees who feel disenfranchised by new process changes they had little input in creating. In addition, the recognition and rewards that typically come with Belt certification will further aggravate rank and file employees.
Making the Transition…Without the Pain
A big price tag and the challenges in deployment all add up to a difficult road for application of Six Sigma in healthcare. However, the experience of several pioneering organizations, along with an emerging set of second-generation best practices for Six Sigma Deployment, offer hope. Healthcare organizations wanting to use Six Sigma can get there faster, more affordably and without pain by shaping their Six Sigma Deployment with the following principles.
- Take a Laser Beam Versus the Floodlight Approach.
Conventional wisdom aside, Six Sigma can be successful without a huge commitment. A few Black Belts with executive support can successfully attack selected high risk/high return performance problems that require Six Sigma statistical tools to achieve breakthroughs.Training large numbers of Black and Green Belts, beyond the capacity of the organization to effectively deploy them results in “make work” projects. Problems get solved but with a return not commensurate with the cost and time invested. - Expand the Tool Kit for Broader Engagement.
For the most part, Six Sigma training does not equip its Belts to deal with the cultural barriers to change. This gap can be fatal in healthcare organizations. The solution, as veteran Six Sigma companies are doing, is to equip Belts early in deployment with methods and tools to engage more physicians, nurses, support personnel and others in the improvement process. The key to involving these “knowledge carriers” efficiently is understanding when their input is most valuable and how it adds to ownership for the outcome.For example, we have found it is absolutely critical to involve professional medical staffs in the redesign of processes and procedures. These are busy folks, so training them in statistical tools and theory they may never use is unproductive. A more effective approach is to use the Belts to define and measure process problems – essentially build the case for action – and then engage the process owners and experts in finding solutions.At the frontline employee level, the DMAIC project model should be complemented with simple, but equally reliable tools for tapping know-how and latent motivation for change. This means offering fast, easy-to-understand and user-friendly avenues for putting good ideas into action. - Refocus and Recharge the Internal CQI Staff.
Six Sigma often threatens CQI managers and other quality professionals in healthcare organizations. In many cases, they end up marginalized and relegated to a regulatory compliance role. For some CQI managers, so long accustomed to “lip service” executive commitment, the heavy accountability associated with running a Six Sigma Deployment process is too great a leap.However, many quality improvement departments in healthcare organizations have proven capabilities, such as identifying patient expectations, measuring patient satisfaction, documenting processes and performing root cause analyses. These capabilities should be integrated into any Six Sigma Deployment. In addition, existing quality action teams should be reviewed. Those that do not have strong business case justification should be retired. Those that do should be elevated to Black Belt project status.
Using these principles as a guide, healthcare organizations can fashion Six Sigma Deployment plans more suited to the needs and realities of their environments. The result will be a transition to Six Sigma without the pain and with bigger gains.
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