CV Leaders Get Lean and Sigma-fied
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.

Problem-solving tools

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

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."

Bottom-up leadership

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, soliciting feedback from frontline nurses about barriers and bringing clinicians from across the system together to share strategies. She then summed up their insights for administrators to design and implement a program that was acceptable for both camps.  

Based on the feedback, Memorial Hermann created a structured program that clearly outlined the CHF criteria, pathways, orders and discharge protocol. They identified and eliminated wasteful processes, such as orders for tests that could be done on an outpatient basis. They integrated more support mechanisms designed to lower the readmission rate. To improve efficiency, they consolidated CHF patients in one hospital area and instituted multidisciplinary rounds including nurses, who initially were reluctant to add anything more to their busy schedules.   

"We followed a template: What are the barriers? Who needs to be involved? Do we need to escalate it? Who oversees the next step?" Baran explains. "All the people were there for the conversation instead of having to make phone calls, which puts the nurse in the middle doing all this follow-up. That was key for getting the nurses' buy-in."

For outcomes, they measured readmission rates, length of stay and cost-per-case. Thirty-day readmission rates for CHF have been lowered by as much as 50 percent, according to one report, and Memorial Hermann now ranks 2 percentage points better than the national average for 30-day readmissions for HF, according to Hospital Compare.

Engaged and onboard

Six Sigma and lean approaches also can be applied in a top-down manner as a compliance-type program, Martin says, but that may be counterproductive. Some staff won't go beyond prescribed rules, while others will resist and work around the initiative.

Deshpande initiated lean processes several years ago when his group was independent. The practice integrated with Columbia St. Mary's Hospitals in Milwaukee, about two years ago, but it maintains a lean sensibility. And, like Baran, Deshpande favors an inclusive approach that he says has paid off in both greater efficiencies and patient and staff satisfaction.

"Bad processes make good people look bad," Deshpande points out, which can frustrate staff. "Plus, it is hard to keep the patient satisfied with a dissatisfied staff."

Deshpande and colleagues hired a facilitator to help them address an unwieldy workflow in the electrophysiology clinic. Their goal was to shorten the time between a patient's office entry and his or her billing. With the facilitator's aid, they determined objectives, processes and timelines; identified hurdles, bottlenecks and inefficiencies; gathered data; and enrolled key participants from all levels to be involved in the process. They also held a meeting that included staff and representatives from their vendors, hospital and other associates to share ideas and discuss potential changes and their ripple effects.  

The solutions were both simple and challenging, Deshpande says. For instance, they streamlined their phone answering by defining responsibilities and expectations. They also strengthened their EMR and revised routing protocols from devices and the EMR to improve accuracy, efficiency and compliance. The result: Patient wait times decreased from days to hours, Deshpande says.

"There was not just an improvement in turnaround time," he says. Physician and staff retention remains high. They have kept an open and solution-focused culture, he says, that includes an administrative representative at clinical meetings and a clinical representative at administrative meetings. A heavily electronic practice, they continue to refine their EMR process.

"Remote monitoring systems change and the ability of devices to communicate with our EMR changes," Deshpande says. "As consumer technology changes, we need to change, too."

Those who practice a bottom-up approach stay true to Six Sigma and lean philosophies, according to Martin, who adds that they needn't stop there. He advocates incorporating what he calls complementary appreciative and inquiry tools. "Look at making things more streamlined, but also ask, 'What do we need to retain? What are our core strengths that we need to leverage?' If you can attach Six Sigma to your existing strengths, then you are more likely to be able to execute them more quickly and with a positive energy."