Six Sigma in Healthcare

Effective use of the Tool Box

Adrienne Elberfeld, Six Sigma Champion, Virtua Health, USA.

Maria H Foschi, Assistant Vice President, Virtua Health, USA.

The integration and coordination of the healthcare system\'s process improvement tools, utilising Six Sigma concepts, Lean, Management Engineers and Information Services are the key to ensure that processes are first assessed and simplified before introducing anything new.

Delivering outstanding patient care in the most safe, efficient manner through streamlined processes is the number one priority for Virtua Health. This is a common goal for many healthcare organisations but it is approached in a very different way at Virtua Health. Rich Miller, President and CEO of Virtua Health explains, "we are dedicated to providing an Outstanding Patient Experience and have harnessed advanced technologies, attracted renowned physicians, employed the very best people in their fields, and instituted processes and procedures to ensure the highest levels of quality and safety-all in the pursuit of providing excellent service within a caring environment."

Serving and meeting customers' needs, higher consumer expectations, rising healthcare costs, an ageing population, easy access to information, and continual advancements in technology are some of the challenges healthcare faces today. Through a strategic partnership with GE Healthcare, which began in 2000, Virtua has successfully leveraged the use of the Six Sigma Tool Kit to overcome these challenges. From Virtua's perspective, a prodigious benefit of the partnership has been the incorporation of new advanced tools and technologies to ensure the delivery of quality clinical service and patient safety.

Use of Six Sigma has resulted not only in statistically significant and sustained improvements but also recognition at local levels.

Virtua promotes innovation, transformation and sustainment of gains or performance in improvements via the use of the Six Sigma Tool Kit which includes the methodologies of Six Sigma (Define, Measure, Analyse, Improve, Control), Design for Six Sigma (Design, Measure, Analyse, Design, Verify), Lean, FMEA (Failure Modes Effects Analysis), Workout and most importantly, Change Acceleration Process (CAP). Tools and techniques are continually evolving and added to the Tool Kit. The DMAIC process and Six Sigma methodology tools are utilised across all of the healthcare processes to achieve process improvements in service, patient and family satisfaction, clinical quality and safety and financial performance.

Virtua Health is currently in its seventh year of project activity, where the use of these tools by internal resources of Black Belts, Green Belts, Management Engineers, Information Services, Operations and Clinical Informaticists, have been successful in improving, streamlining and standardising clinical and non-clinical processes throughout the organisation. Individuals at all levels within the organisation participate in Six Sigma projects and utilise the tools not only in specific projects but also in their day-to-day operations. Upon hire, all employees receive training on the use of DMAIC as the model for improvement. All participants in a DMAIC, DMADV or Kaizen team receive foundational principles training for each Six Sigma process phase. All Virtua managers are required to obtain their Yellow Belt certification, which provides them with a general understanding of the Six Sigma Tool Kit, knowledge of statistical process control and the skills to facilitate the utilisation of these tools. Green Belt training is provided to key project facilitators and is available to anyone at any level within the organisation. All of these training efforts contribute to driving Six Sigma into the Virtua Health culture as the key process improvement method.

Senior management scopes, evaluates, prioritises and sponsors all projects throughout its lifecycle. All levels of the organisation utilise these tools and participate in these projects. Senior leaders also participate, where titles are "checked at the door" promoting frank, two-way communication and dialogue with direct staff members. There is a quarterly session at which a report out is provided on the projects utilising the tools and, the results and status are shared with Senior Management. All Senior Leadership including the CEO / President, Executive Vice President of Health Services, CMO and all Chiefs, Vice Presidents and Assistant Vice Presidents are expected to attend. The report outs are also a way to reinforce empowerment and to motivate the team members by giving staff level employees an opportunity to "shine" by sharing their knowledge and content expertise with Virtua leadership.

The use of the Tool Kit has realised a financial impact of more than US$ 25 million and it continues to grow; however, it is the quality of care influence, that has been most impressive, as the application of the methodologies in project activity has been transformational. Use of Six Sigma, (DMAIC), in addressing Centers for Medicare & Medicaid Services core measures for Cardiac Medication Administration, Pneumonia, Surgical Infection Prevention, and most currently Normothermia (Surgical Care Improvement Project), have resulted not only in statistically significant and sustained improvements but also recognition at national and local levels (Table 1). The application of Design For Six Sigma and Lean concepts partnered with Information Services has resulted in designing a surgical registration and scheduling system based on the voice of the customer. This methodology was also utilised in creating a Breast Care Navigation Model, which supports patients diagnosed with breast cancer through the continuum of care.

The discipline of using the Six Sigma Tool Kit to obtain the true voice of the customer and rigour in improving current state processes is even more critical as Virtua breaks ground on a state-of-the-art acute care facility and two ambulatory centres, expands various clinical programmes, implements the newest technologies and applies for the Malcolm Baldridge Award for quality. "It's our ability to identify the key processes that drive our business and work with operations to focus on the appropriate tools and resources to improve these processes that will be critical moving forward", says Adrienne Elberfeld, Master Black Belt, Six Sigma Champion, Virtua Health.

Virtua Health uses in-process and outcome indicators to monitor the control and improvement of healthcare processes. These measures are developed in the MEASURE phase of DMAIC when new processes are being designed or current processes are redesigned. Data collection and performance measures are determined in the MEASURE phase. Critical To Quality (CTQ) are defined by customers as the key requirements of a particular healthcare process is obtained and the CTQ is translated into a "Y" or measurable outcome. During the MEASURE phase of DMAIC, the "Y" data is obtained to understand how the process is performing against customer specifications (defect rate) and a baseline of performance is established. In ANALYSE, the team utilises the data to understand the process root cause drivers and then develops an improvement plan. IMPROVEMENT strategies are piloted and remeasured to determine if the strategies demonstrate a statistically significant difference in improving the "Y" while decreasing process variation. In the CONTROL phase, the defined measures are tracked to assure statistical process control (stable and reliable) meet the customer's specifications. The process is maintained and monitored by the DMAIC process owner. If the process becomes out of control and / or unstable, a review of root causes is commenced, and actions plans are implemented to regain control and stability. If the process owner needs assistance to understand why the process is not in control, resources are made available to implement DMAIC tools. Improvement strategies developed are compliant with regulatory, accreditation bodies, payers, patient and operational requirements.

Virtua minimises overall costs, reduces redundancy and prevents errors and rework through improvement processes such as Lean, Six Sigma, DFSS and FMEA. These services and processes are piloted to test that errors, rework, safety and functionality requirements are intact.

Ninfa Saunders, Executive Vice President of Health Services, has recently challenged the organisation to also incorporate the Six Sigma Tool Kit in all technology implementations. Saunders states, "rather than just fixing a broken process with a technology solution, Black Belts, Green Belts, Informaticists, Management Engineers, Information Services, Clinicians and Operations will work together to assess the current state and determine which technologies could enhance our processes to deliver the best care to our patients."

The biggest challenge, both from a resource and process perspective is the technology transformation. The integration and coordination of the system's process improvement tools, utilising Six Sigma concepts, Lean and CAP have been the key to ensuring that current state processes are first assessed and simplified before introducing any new technology.

The appropriate tools are utilised in all technology implementations both in the clinical and non-clinical departments. The use of the improvement tools is incorporated in the technology project methodology business practice and they result in positive changes to the processes and workflow prior to the technology implementation. Systems are then designed and built to accommodate the new improved workflow. "No longer can new technology be implemented in a silo; it's the on-going coordination with Operations and using the process improvement tools that will yield the best results", explains Maria Foschi, Assistant Vice President, Information Services, Virtua Health. "This is a huge cultural change and we wouldn't be successful if we didn't appreciate the 'people aspect' as we change workflow, process and technologies."

Virtua is utilising all the tools within the Tool Kit as they undertake a major implementation of a fully Electronic Medical Record (EMR) and many other clinical supporting systems. Key individuals including clinicians, physicians, nurses and corporate staff across the enterprise are looking closely at each of the key healthcare processes early in the EMR planning and designing phases. Workflows and processes are designed to reduce risks and errors while minimising costs. Systems are then designed and built to support the newly designed workflows and processes.

Voice Of the Customer (VOC) along with the use of all the Six Sigma Tool Kit is the major influence that adds value as Virtua successfully ensures that the delivery of patient care is safe and efficient.

Virtua Health has made effective use of the "Tool Kit" in improving processes and its innovative partnerships with nationally known organisations evolving into an to organisation dedicated to providing a world-class patient experience.

Virtua Health is a multi-hospital healthcare system headquartered in Marlton, New Jersey, USA. Its mission is to deliver a world-class patient experience through its programmes of excellence in cancer treatment, cardiology, orthopedics, women's health, pediatrics, surgery, neuroscience and geriatrics. A non-profit organisation, Virtua employs 7,450 clinical and administrative personnel, and 2,100 physicians serve as medical staff members.

Author Bio

Adrienne Elberfeld

Adrienne Elberfeld is currently the Six Sigma Champion at Virtua Health in Marlton, New Jersey. As one of the Master Change Agents at Virtua, she also coordinated the training and development of the CAP and WorkOut processes. Her responsibilities include overseeing all Six Sigma Black Belts and Green Belts, co-developing curriculum for Six Sigma education, driving system-wide projects and customising the Six Sigma methodology to best suite Virtua's needs. She is also a Malcolm Baldridge certified board examiner for the New Jersey Quality.

Maria H Foschi

Maria H Foschi is responsible for the management of information technology financials, processes, and planning for Virtua Health. Foschi has more than 20 years of progressive experience implementing systems and managing information services in multiple areas. Prior to this position, Foschi served as interim CIO / VP of Information Services. She also was Assistant Vice President, Information Services for Customer Relations and Customer Support at Virtua Health.