Six Sigma and lean processes emerged from the manufacturing industries as methods to increase reliability and eliminate waste with the goal of improving quality. Six Sigma's data-driven, customer-focused, step-by-step methodology and lean's focus on value are becoming more widely embraced by both large and small healthcare providers, according to physician executives and management specialists. But the key to their success is not the approaches themselves, but rather how they are applied.
Julie Baran, RN, former director of invasive cardiology and now a Six Sigma Master Black Belt at Memorial Hermann Healthcare System in Houston, and her colleagues knew that the 11-hospital system with its 22,000 employees needed to overhaul its congestive heart failure (CHF) program. Some CHF patients were being misdiagnosed when admitted, which led to late treatment, longer stays and readmissions.
When workflow and EMR inefficiencies began causing avoidable delays, Sanjay Deshpande, MD, medical director of electrophysiology at Columbia St. Mary's Hospitals in Milwaukee, Wis., also realized that his 20- to 25-person practice group was in need of a change.
Baran and Deshpande knew that such changes, if designed and implemented correctly, could improve both efficiency and morale. Using the principles of Six Sigma and lean practices, these leaders helped to define a shared goal and navigate their respective staffs toward improved efficiencies.
Six Sigma vs. Lean Processes
|FACTOR||SIX SIGMA||LEAN PROCESSES|
|Focus||To reduce process variation||To improve process flow and eliminate waste|
|Methods||Define, measure, analyze, improve, control||Value stream mapping: find and change root cause of non-value-added activity|
|Role of executive leader||Champion sponsor||Champion sponsor|
|Role of physician/clinical leaders||Master Black Belt, Black Belt, Green Belt member; member of project team; subject matter expert||Member of project team; subject matter expert|
|Adapted from the Physician Executive, May/June 2007; Institute for Healthcare Improvement|
"Both lean and Six Sigma are problem-solving tools; they look at what's wrong," says William Martin, MPH, PhD, an associate professor in the department of management at DePaul University in Chicago. In a 2007 American College Physician Executives survey, Martin found that 18.5 percent of physician executives chose Six Sigma as their quality of care approach, 13.3 percent favored a lean process and 12.2 percent relied on products from vendors. About one-third had no program and another 26.7 percent used a homegrown approach.
For those considering Six Sigma or lean, Martin recommends emphasizing the potential benefits to the organization, both to the patients and staff, especially if employees see the process leading to cost cutting or job reductions. "A clear vision has to be created and articulated; that's where leadership comes into play," Martin says. "Make sure you communicate the goals, the milestones and feedback as the group gradually begins to achieve progress, and tie it back to the purpose and importance of everyone involved."
Baran has spearheaded several quality initiatives, including a progam designed to shorten hospital stays for patients admitted with CHF in Memorial Hermann's nine acute care facilities. Multiple problems impeded care: The hospitals followed internal and external evidence-based best practices, but not uniformly throughout the system. Misdiagnoses in the emergency room meant delays in the start of CHF orders and unnecessary tests.
"Sometimes, the CHF pathways wouldn't get started until day two or three," Baran says. "When you are looking at a length of stay that should be four days or less, and you don't identify someone as needing pathways until day two or three, then you are really behind the eight ball."
Six Sigma and lean processes can benefit both large and small organizations, Martin says, but each size offers challenges. Small groups typically lack the expertise and time to follow the framework, generally relying upon consultants to help them along. Large systems may have the resources, like Black Belts on staff, but the problems usually cross multiple departments, which slows the process and adds complexity.
For Baran, the solution lies in communication skills and an ability to understand what motivates both clinicians and administrators. In the CHF initiative, she applied a bottom-up approach,