Chapter 8. Case Study Introduction and Profiles

During the mid-1990s, the healthcare industry began searching for better process improvement models. Past re-engineering efforts and quality programs had failed to sufficiently address systemic inefficiencies or deliver sustainable results. Short-term cost-cutting measures may have presented a better financial picture temporarily, but the gains tended to unravel over time. Without a viable tool to expose and deal with actual root causes, one of the primary targets for slashing the budget became labor. Unfortunately, simply trimming the workforce wasn’t the answer and did not produce the desired long-term effect. By the 1990s, programs like Total Quality Management (TQM) had begun to run their course—at least within the United States—and other approaches had evolved.

“Remember quality circles?” says one hospital Black Belt. “There was a reason we went in circles—we were always coming back to the same issues because they were never fully resolved. Six Sigma has allowed us to really zero in on the right things and make sure solutions stick.”

Six Sigma offers distinct advantages over traditional quality initiatives:

• Focuses on customer requirements, instead of vague quality goals

• Targets defects and process variation instead of averages

• Provides a highly structured, data-driven framework for problem-solving

• Includes a robust Control phase and tools to maintain results

In a 1998 article “Is Health Care Ready for Six Sigma?” (The Milbank Quarterly, Vol. 76, No. 4, 1998), Dr. Mark Chassin noted serious challenges facing the industry and discussed the possibility of using Six Sigma to drive fundamental changes within the system. In the end, he noted that “...enough examples of improvement exist to conclude that we can do much better. We can learn a good deal from industries that are working toward the Six Sigma goal. Let’s try it in health care and see how close we can get.”

Since that article was first published, an impressive track record has steadily developed within the industry. Thousands of projects tackling a host of clinical and operational issues have been completed within healthcare—from small rural facilities to large multi-hospital systems.

Although not every issue requires the rigor of Six Sigma, it is applicable to healthcare because it is adaptable to a wide range of situations and settings—from lengthy wait times to process delays to prescription errors. There are countless opportunities for improvement across the continuum of care. Translating and scoping these opportunities into executable projects with measurable results can have a significant impact on the cost and quality of patient care. When used as part of a broader framework for change, Six Sigma can also have a positive effect on organizational culture. One key to its success—where other change initiatives may have fallen short—may be a higher level of rigor, detail, and follow-through.

Healthcare providers currently considering an improvement initiative that includes Six Sigma methodologies should have a distinct advantage over their predecessors. They will likely have a stronger foundation on which to build, thanks in large part to efforts by early adopters. Reviewing the experiences and lessons learned by healthcare’s “Six Sigma pioneers” can offer guidance for the next generation of practitioners.

Many “early adopter” healthcare organizations are now self-sufficient with their own internal training programs and a strategically aligned project funnel. They have demonstrated that with the right planning, guidance, resources, and perseverance, a Six Sigma journey can be truly transformative. This is not to imply, however, that success will materialize overnight, or that the road ahead will be entirely smooth. As Kathy Gallo, Ph.D., RN, North Shore-LIJ Health System, said, “Six Sigma is not for the faint of heart.” Challenges are to be expected. Those organizations that invest sufficient time and energy into front-end planning seem to encounter the least resistance as the program is rolled out. The importance of understanding the voice of the customer and gaining early “buy-in” from key stakeholder groups should not be overlooked.

Table 8.1 is not a complete listing of all hospitals and health systems using Six Sigma, but it does provide some idea of both the reach and the staying power of this methodology in healthcare provider organizations.

Table 8.1. Healthcare Organizations Using Six Sigma Strategies

Within each organization, Six Sigma has been adapted to fit the existing culture, objectives, and readiness for change. It has been applied to address many common challenges in healthcare, including medical errors, technology workflow, market growth, resource utilization, length of stay, and patient flow or capacity issues. A wide variety of hospitals and health systems have used this methodology, often in combination with other tools, to help create a better patient experience, increase efficiency, and improve the operating margin.

In some cases, Six Sigma was initially employed to focus on a specific department or process, and in other cases it has been implemented on an enterprise-wide basis to create self-sufficiency and a common structure for problem-solving. Several profiles are offered in the following sections as examples of various deployment strategies in the healthcare provider sector.

Commonwealth Health Corporation, Bowling Green, KY

Generally recognized as the first healthcare provider to implement Six Sigma on a system-wide basis, Commonwealth Health Corporation (CHC) is a 490-bed non-profit organization located in Bowling Green, Kentucky, with more than 2,500 employees.

In late 1997, John Desmarais, president and chief executive officer of CHC, attended a conference and heard Jack Welch speak about Six Sigma and culture change at General Electric. Inspired by the encounter and the results attributed to this rigorous approach, Desmarais soon began working with GE to adapt Six Sigma and related change management methods to his own healthcare organization.

Taking a phased approach to training and implementation, the CHC Six Sigma team focused its initial efforts on four organizational priorities: customer satisfaction, quality of care/service, timeliness/speed/convenience, and cost. Their approach consisted of four phases:

• Phase One: Radiology. In May 1998, the first wave of training began with 13 participants focused on issues in radiology. Projects from this phase led to shorter wait times for patients, faster turnaround times for radiology reports, a 25 percent increase in throughput, and a 21.5 percent decrease in cost per radiology procedure.

• Phase Two: Management Training. During the second phase, 74 managers participated in ten days of change management training, and cross-functional teams tackled issues with patient registration, employee empowerment, communication flow, customer service, human resources, and the medication process. The teams acquired skills while addressing major organizational priorities.

• Phase Three: Billing. Training for the second Green Belt class began in November 1998, and consisted of 15 participants focusing on specific processes within the billing department. The CEO and senior management team received Green Belt training during this phase and shadowed the projects. This team identified key indicators for the billing process vision, created a process map, and defined the “critical to quality” elements. They analyzed variances and identified potential quality improvement targets. Results from this team’s efforts included reduced billing cycle time, more efficient charging procedures, and less returned mail.

• Phase Four: Training the Trainer. Two employees were chosen to become Black Belts and eventually Six Sigma instructors and mentors. Eight other employees were trained as change agents. Gaining and transferring skills helped the team to become self-sufficient and pursue other improvement opportunities.

By the end of 2001, more than 2,000 employees had attended at least one full day of Six Sigma awareness training, during which they were introduced to basic concepts of the methodology. Initial projects generated annual savings of $276,188 in billing, decreased annual radiology expenses by $595,296, and reduced errors in the MR ordering process by 90 percent. Within 18 months, CHC had achieved higher efficiency, an improved patient experience, an elimination of more than $800,000 in costs, and perhaps most importantly, a reenergized culture.

Despite challenges and resource fluctuations along the way, the program at CHC has remained on track and evolved over time. As a pioneer in this effort, CHC shared some keys to success with Six Sigma:

• Provide ongoing support from senior management.

• Make sure this is not viewed as just a financial re-engineering effort, but as an evidence-based approach to operational and clinical improvement.

• Persistence is another key: Define your objectives and stick with them.

• Articulate the vision clearly and spell out the CTQs (Critical To Quality elements) to the organization. If you don’t have four or five elements you’re focused on, the results can become diluted.

“Six Sigma has become the capstone to the pyramid of quality we’ve built over the years,” Desmarais noted in 2000. “It brings everything to a whole new level. The competitive edge the organization has gained through this process is incredible.”

The team at CHC develops its own materials, conducts training sessions, and mentors Brown Belts through various levels of operational and clinical projects across the organization. Despite some unavoidable challenges along the way, CHC has seen many positive results.

Pockets of early resistance faded as the “belts” established a track record. The use of change management tools helped by involving those closest to the process and making critical decisions more quickly based on reliable data. To keep the momentum going, they held Green Belt fairs and featured Six Sigma news in the organization’s monthly newsletter. Display boards in the hospital are used for posting project summaries and results. CHC’s board of directors has remained involved and supportive. Six Sigma projects are highlighted at board meetings.

“Unlike Six Sigma, previous initiatives were not well-defined and provided no data-driven roadmap to follow,” says Jean Cherry, executive vice president at CHC. “Having access to solid data and proven processes behind the mission has helped to increase the level of confidence throughout the organization.”

CHC is continuing its performance improvement program and will be incorporating other tools such as Lean to eliminate waste or non-value added steps. Projects still flow into one of three dashboards measuring cost, customer satisfaction and timeliness, speed, and convenience.

The Six Sigma program remains active at CHC, but it is more integrated with other quality initiatives now, rather than treating it as a distinct function when the program was first launched. The teams report through the vice president of quality management, and CHC now has three Master Black Belts focused on a variety of clinical and financial projects. There are more than 120 trained Green Belts, along with “Brown Belts” who work on projects on a part-time basis.

CHC is still using the change management tools, and Black Belts continue to mentor and monitor projects. Six Sigma has been used within a Premier/CMS demonstration project focused on five clinical conditions. Coronary Artery Bypass Graft (CABG) compliance is now at 100 percent, and teams are working on improving the care of patients with pneumonia and heart failure, hip and knee replacement, and acute myocardial infarction (AMI). Additional projects have been completed in radiology, adjusting workflow to accommodate a new Picture Archive and Communication Systems (PACS) implementation, and introducing an electronic signature for radiologists.

CHC was one of more than 3,000 healthcare providers who became involved in a 2005 campaign led by the Institute for Healthcare Improvement to save 100,000 patient lives by avoiding unnecessary errors. Projects to support this campaign included reducing central line infections and hospital-acquired pneumonia, and implementing a rapid response team. To align with JCAHO recommendations, they have encouraged managers to use statistical tools such as control charts. One of the most noticeable and lasting benefits, however, has been a change in organizational culture. According to Jean Cherry, managers now make decisions based on a much deeper analysis of their operation.

Virtua Health, Marlton, NJ

Located in southern New Jersey, Virtua Health was formed in 1998 by the merger of two health systems, and now includes four hospitals, outpatient centers, long-term care facilities, home health, ambulatory care, and a fitness center. The system has roughly 8,000 employees and 2,000 physicians. Six years after launching a large-scale improvement initiative that included Six Sigma and change management, the system is now recognized as a high-performing organization and a model for others to follow.

In 2000, however, this healthcare provider was considered somewhat average by most benchmarks. Being average wasn’t satisfactory to Richard Miller, president and CEO at Virtua Health, who felt the organization needed a new strategy to drive breakthrough improvements, create a culture of excellence, and support its “STAR” initiative (see Figure 8.1).

Figure 8.1. Systems and structures to support the STAR, Virtua Health

Miller initially had become interested in Six Sigma based on case studies from other industries, and ultimately decided to bring the methodology into his own health system. At Virtua, Six Sigma became part of a broad educational and process improvement initiative enabling staff to become self-sufficient in leading change initiatives. Since the program was launched, every Virtua manager has been trained to at least the Yellow Belt level in Six Sigma, and there are also 56 Green Belts, 20 Black Belts, 5 Master Black Belts, and numerous change agents.

“Change in healthcare is hard no matter what area you are focusing on,” says Carol Mullin, RN, Master Black Belt in the Six Sigma program at Virtua. “It is especially difficult with respect to patient safety issues and projects, because you’re talking about a huge cultural shift for everyone involved. You can’t begin to come up with workable solutions until people first admit there’s a problem. The cultural changes in healthcare are often more important than the technical solutions, because they require you to look at how people get their work done and how they were educated to do certain things.”

With measurable results in key areas such as the surgical suite, emergency department, and cardiovascular services, this health system in New Jersey has shown it has what it takes to transform its culture, keep the momentum going, and make change stick.

Virtua continues to receive national recognition and awards for its efforts. In addition to improving patient services and transforming the culture, Six Sigma initiatives added roughly $15 million in new revenue to Virtua’s bottom line within just five years. This figure does not include projected savings or financial benefit from numerous Work-Out sessions, which also contribute to a healthier operating margin.

“There used to be a mindset in healthcare that raising quality meant raising the costs,” says Miller. “But we’ve learned that in many cases, higher quality also means lower costs.”

Miller believes it’s important for the CEO to play a very active and visible role in the initiative. “I attend every Six Sigma report-out on a monthly basis,” he says, “and I’m involved in our best people review. We also brought in a new learning and leadership approach, and this has fundamentally changed our organization. It has really put accountability in the system, and that was key.”

A few of the results so far include projects that

• Reduced the incidence of surgical site infections by improving the administration of antibiotics within one hour of incision from 90 percent to 97 percent

• Improved the accuracy of the home health coding process by the clinical staff, which led to overall agency HHRG (Home Health Resource Group) case weight mix increase to 1.33 for Virtua West Jersey Hospital and 1.36 for Virtua Memorial Hospital, resulting in an increase of $615,000 in Medicare revenues within just six months

• Increased insurance reimbursement for surgically implanted devices such as artificial joints, which saved the hospital more than $2 million

Multiple projects have been able to reach Six Sigma levels of excellence, and the team continues to seek further opportunities to improve. Rich Miller has remained steadfast in his commitment to the program and in continuing to explore new avenues for creating the optimal patient care experience. His visible support, along with recognition for results, has helped to maintain the momentum and enthusiasm among staff. Transparency and accountability—two elements crucial to transforming healthcare—are clearly apparent at Virtua. Employees feel empowered to seek workable solutions instead of becoming complacent or assigning blame. Dr. Mark Van Kooy, Master Black Belt and chief medical information officer at Virtua, puts it this way: “We’re more forward-looking now than backward-looking. Everyone understands the concept of accountability; there is no excuse-making or finger-pointing anymore.”

According to Van Kooy, Six Sigma is viewed at Virtua as a business tool rather than a quality tool. “Quality, however, is one of our most important businesses. Clinically, we have used Six Sigma to address issues such as the safety and efficacy of acute anticoagulation, administration of CMS cardiac medications for AMI and congestive heart failure (CHF), CHF length of stay, rehab services response time, and restraint usage documentation. Many more of our projects have been in core business functions such as billing and collection. This has had a very favorable impact on our bottom line and allows us to reinvest in critical areas of the organization that directly impact patient care.”

Virtua has also adopted new operating mechanisms and Lean techniques to augment their Six Sigma program, and they have created a highly integrated performance improvement structure. Leveraging innovative management methods, Rich Miller and the team have succeeded in creating a high-performing organization at Virtua.

Valley Baptist Health System, Harlingen, TX

Valley Baptist Health System, based in Harlingen, Texas is a not-for-profit community health network that includes a 611-bed regional academic referral hospital. Through the leadership of Jim Springfield, president and CEO, it began to implement Six Sigma in May 2002. Since that time, they have improved numerous processes related to the emergency department, outpatient services, surgical services, diagnosis-related grouping (DRG) assignment accuracy, pain management, JCAHO Core measures for AMI, CHF, and pneumonia, and admissions and discharge. They calculate a return on investment of more than $25 million from 2002 to 2006.

As of 2006, 72 Six Sigma initiatives and more than 340 Work-Outs have been completed across Valley Baptist. The projects have had a direct “line of sight” to the strategic objectives of the business and have resulted in decreased cycle times, process standardization, increased customer satisfaction, and financial benefits. A number of initiatives achieved Six Sigma performance levels including AMI, heart failure management, and the patient ID process.

In January 2007, Valley Baptist Medical Center-Harlingen was ranked number one in the United States in the treatment of heart failure, according to a pay-for-performance project conducted by the federal government (http://www.genengnews.com/news/bnitem.aspx?name=11837169&taxid=35).

In addition to the top ranking for heart failure treatment, Valley Baptist placed in the top 10 percent in the nation in treating heart attack (acute myocardial infarction) patients. The U.S. Centers for Medicare & Medicaid Services (CMS) and Premier, Inc. conduct the demonstration program to reward quality and performance among the nation’s hospitals.

Valley Baptist attributed the improved patient care for heart failure and heat attack patients to Six Sigma.

Beyond specific financial returns and better quality metrics, Springfield views Six Sigma as ‘a means to an end,’ with the end being cultural change and the notion of constantly raising the bar to create a better environment for patients.

In 2004, Springfield received the American College of Healthcare Executives’ Robert S. Hudgens Memorial Award for Young Healthcare Executive of the Year, in part for his innovative leadership and commitment to creating a better healthcare delivery system through Six Sigma and change management. He has noted that Six Sigma shares similar tenets and statistical tools with other quality improvement efforts, but at a higher level of implementation. He also recognized the importance of addressing the “people” side for change along with statistical process control.

“It doesn’t matter how good a solution may be,” he says. “If it’s not culturally accepted, the results will be diminished.”

The Six Sigma team at Valley Baptist strives to ensure that efforts produce both quantitative and qualitative results, taking on projects that are highly visible and touch a lot of people within the organization. As a result of the changes Springfield and his staff have implemented, Valley Baptist has seen significant improvement in many areas throughout the system, including operating room turnaround time, order entry, pharmacy turnaround, discharge process, emergency room turnaround time, and laboratory results reporting. Launching this initiative required a significant up-front investment in terms of training, resources, patience, and dedication, but the benefits have been even more significant. Springfield has noted that financially, they have probably seen a 15-fold return on their investment.

“Healthcare is generally ineffective, and we focus on the wrong things,” says Springfield. “So we asked how can we afford not to invest in this? We initially spent a lot of money—but we got a huge return, both qualitatively and quantitatively. I would counsel other organizations not to take a shallow view. If they don’t want to make the investment, they may be saying they don’t believe they can get these results. You’re investing in better quality and the capability of your people.”

One early project targeted staff scheduling and led to an overall reduction in the higher hourly cost of overtime and agency use, achieving Six Sigma performance from a baseline of zero. This project translated to $460,000 in savings for one unit; Springfield offered a conservative estimate at the time that if it were spread across the system to all units, the project could potentially save more than $5 million. This also provided a classic example as to how Six Sigma can be used to either corroborate or dispel original theories. Management had initially assumed they were over budget on labor costs due to sick leave, FMLA, vacation, and people not showing up, causing the need for the additional overtime and agency hours. Statistical analysis disproved those assumptions, pointing to factors such as nursing dissatisfaction with frequent rotation between different units and issues with the staffing matrix, which attempted to set parameters based on volume.

Internal training efforts have continued, and as of May 2006, the program included 297 Change Agents, 5 Master Black Belts, 4 Black Belts, 61 Green Belts and 34 Yellow Belts. Springfield has emphasized that their program is really about cultural acceptance and changing both processes and behaviors. “We always respect people, and that’s important,” he said. “And we recognize effort. But we reward performance.”

All the improvement initiatives at Valley Baptist Health System are tied to a rigorous performance measurement system and structured operating mechanisms that enable project linkage to their top goals and objectives. Managers track results using control charts and trend reports with data from human resources, time and attendance, and payroll systems. This provides real-time information on productivity, tracking worked hours versus patient days to show alignment with targets on an ongoing basis.

North Shore-Long Island Jewish (LIJ) Health System, NY

The North Shore-LIJ Health System is headquartered in Great Neck, New York, and includes 15 hospitals, 4 long-term care facilities, 3 trauma centers, dozens of ambulatory care centers, and 5 home health agencies throughout Long Island, Queens, and Staten Island. It is the third-largest nonprofit, secular healthcare system in the U.S., with about 37,500 employees and more than 6,000 beds.

In January 2002, North Shore-LIJ launched its Center for Learning and Innovation (CLI) in conjunction with General Electric and the Harvard School of Public Health. The CLI features several programs:

• Learning initiatives for new and existing employees and managers

• An “Innovative Solutions” division that focuses on organizational development, leadership practices, workforce development, and performance management

• An Operational Performance Solutions group that uses Six Sigma and Lean methodologies to improve efficiencies and enhance quality within its hospitals and facilities

• Nursing and physician leadership institutes for clinical managers

• Critical Care and Emergency Department Nurse Fellowship programs

• A technical education arm that provides certification programs in the allied health professions

• Patient Safety Institute, which features a simulation lab with three computerized mannequins that allow medical students, surgical residents, nurses, and other healthcare professionals to practice their clinical skills without risk to real patients.

Since CLI opened in 2002, North Shore-LIJ has achieved positive results throughout the organization. In addition to improving the environment for both patients and employees, it has achieved more than $5 million in cumulative cost savings from Lean and Six Sigma efforts, and is able to explore a variety of growth opportunities (see Table 8.2).

Table 8.2. Examples of Six Sigma/Lean Projects at North Shore-LIJ

“We’re a much better place because we made a solid commitment to improving our workplace,” says Michael Dowling, president and CEO of North Shore-LIJ.

Developing the Six Sigma program and building a full curriculum through the CLI represents a clear commitment to ongoing education and continuous improvement. It also indicates a substantial investment in the development of their people.

“While we recognize the importance of demonstrating quality and financial improvement, the impact on the team is perhaps even more important,” says Alan Cooper, Ph.D., MBA, vice president of learning and innovation. “We have certainly seen some great results from projects that contributed to our bottom line, but it’s the professional and leadership development that has really made a difference in our organization.”

Nancy Riebling, MS, MT (ASCP), is a Master Black Belt and director of operational performance solutions at North Shore-LIJ. She has been instrumental in driving numerous improvement projects for the health system. “By leveraging a common set of tools and techniques, we have continued to achieve solid results in a variety of areas across the organization.”

Kathleen Gallo, Ph.D., RN, said hospital executives had decided to use Six Sigma as a management vehicle because they wanted to improve productivity and efficiency. North Shore-LIJ became self-sufficient within three years. The executive leadership team remains actively involved in the program, and educational initiatives through CLI have continued to expand to include the use of Lean and other key management strategies.

Thibodaux Regional Medical Center, Thibodaux, LA

Located in southeastern Louisiana, Thibodaux Regional Medical Center (TRMC) is a case in point to prove that organizational size is not the determining factor for successfully implementing a Six Sigma or Lean program within a patient care environment. A growing, acute-care medical center with 187 beds, TRMC provides a wide range of outpatient and inpatient services to the surrounding region.

In addition to weathering the usual financial storms and resource issues that affect other hospitals, TRMC had to weather storms of a different kind in 2005 when Hurricanes Katrina and Rita barreled into the Gulf Coast. Along with caring for hundreds of hospitalized patients, the physicians and staff worked around the clock for weeks on end to treat the thousands who came through Thibodaux Regional’s emergency department and the shelter located at nearby Nicholls State University.

Greg Stock, president and CEO at TRMC, said he was extremely proud of his team’s performance during this chaotic time, and believes their ability to function well as a team came in part from the strong foundation they had built over the years with Six Sigma and change management techniques.

“Nobody could fully prepare for the sheer size of the storm and the aftermath,” says Stock, “but we found that all the hard work we’d put into improving processes and strengthening leaders really paid off. Disasters deserve our immediate attention and critical thinking. Although we can’t predict or control them, we can prepare our own organizations so that we’re in a constant state of readiness. This has a lot to do with the processes you have in place, teamwork, and the vibrancy and flexibility of the culture.”

The hospital uses Press Ganey to measure both employee and patient satisfaction, and their scores have been very high in both areas. Using Six Sigma and other tools, they have consistently ranked in the top 1 percent in the nation for patient satisfaction within the past six years, and their employee satisfaction survey went from the 53rd percentile in 2000 to the 97th percentile in 2005.

“Pursuing and achieving excellence with regard to patient satisfaction and quality requires a high-performance culture,” says Stock. “Staff members must be enabled through disciplined performance improvement methodologies that drive best performance.”

Internal training and projects continue to focus on the issues that are most important to achieving excellence in patient care. To support system-wide quality initiatives and complement their Six Sigma program, TRMC also adopted Lean methods and DIGs, or “Do It Groups,” which are guided by trained facilitators and are designed to quickly resolve problems and take advantage of opportunities within a 30-day period. Keeping everyone informed about the improvement initiatives is accomplished through departmental meetings, town hall meetings, project report-outs, and presentations at leadership sessions.

“Communication is essential to the success of any performance improvement effort,” says Darcy Prejeant, RN, Master Black Belt at TRMC. “The more staff you have involved in generating solutions, the greater buy-in you will have in maintaining improvement efforts. It is essential to have the masses thinking performance improvement in their daily roles, in order to create a culture of excellence.”

NewYork-Presbyterian Hospital, New York, NY

NewYork-Presbyterian Hospital (NYP) is the flagship of the NewYork-Presbyterian Healthcare System, the largest nonsectarian, nonprofit healthcare system in the U.S. The hospital is a 2,335-bed academic medical center affiliated with two of the nation’s leading medical colleges: the Columbia University College of Physicians and Surgeons, and the Joan and Sanford I. Weill Medical College of Cornell University. At the 2006 Global Six Sigma Awards, NYP received the Best Achievement of Six Sigma in Healthcare Award and also were recognized with the Platinum Award for Outstanding Organizational Achievement for their embrace of the Six Sigma culture.

NYP developed a vision to provide the highest quality service in the healthcare industry using a collaborative, interdisciplinary approach to performance improvement. In 2003, senior leadership took a major step toward transforming this vision into reality. After carefully considering the need to anticipate and respond to shifting trends in the industry, they decided to embrace the Six Sigma philosophy for performance excellence. Chief Quality Officer for the system, Mary R. Cooper, M.D., J.D., became the champion for the implementation and helped to guide the program. Some of the criteria for selecting projects included clinical excellence, regulatory and safety, physician satisfaction, staff satisfaction, patient satisfaction, ease of implementation, financial benefits, time to complete, and sustainability.

Several objectives factored into the organization’s implementation of Six Sigma:

• Achieve knowledge transfer

• Foster transformative cultural change

• Build accountability

• Instill management discipline

• Ensure no one is left behind

• Reach all levels, all disciplines

The curriculum was designed to include DMAIC, Change Acceleration Process (CAP), Work-Out, Lean and Design for Six Sigma, and training was conducted for 17 days over a six-month timeframe. The training was based on completion of actual projects, and each team was composed of a Black Belt working with three or four Green Belts. Project teams eventually expanded to include other key stakeholders. Abbreviated training was delivered to senior administration, medical staff, management staff, and line employees. The curriculum has been repeated five times over subsequent waves of training.

Completed projects include the following:

By the end of 2004, the program’s first full year, the hospital had realized a savings of $47 million through 130 completed projects that were linked to the hospital’s strategic objectives. The hospital takes pride in the fact that many Black Belts have now been promoted back into the organization. In 2006, the hospital received 105 applicants for 10 open Black Belt positions—the majority of which were internal—demonstrating the momentum that had been established and allowing the organization to be selective in choosing candidates. Two were promoted to vice president level from the Black Belt position; four became Master Black Belts. All Black Belts from the first wave of training and half of the Black Belts from the second wave have been promoted back into the organization.

“I believe this is a testament to the leadership development aspect of Six Sigma,” says Mary Cooper, M.D., J.D. “Participants in the program are very attractive to those who are hiring, and having the Black Belts dispersed out into the organization has been very helpful. There are now more than 200 Green Belts trained, and all the Black Belts are still committed and highly motivated.”

In 2005, NYP also adapted GE’s management and leadership systems, and created a year-round operating calendar with clear deadlines, hand-offs, and accountability. Projects have effectively addressed a wide range of safety, quality, operational, and technical issues. As of August 2006, the health system reported $68 million in financial benefits from improvement initiatives within two years. Since 2003, NYP has succeeded in building a solid framework that includes Six Sigma, Lean, CAP, Work-Out, and new management models.

Decatur Memorial Hospital, Decatur, IL

Decatur Memorial Hospital is a 300-bed community-based hospital in Illinois with approximately 2,500 full time employees. In 2001, the hospital launched a Six Sigma program to train staff and pursue projects that align with the organization’s strategic objectives.

As part of this alignment, the team is encouraged to focus on “noble goals,” or efforts that support a noble purpose, such as raising patient satisfaction or preventing hospital-acquired infections. Results are monitored through the hospital’s scorecard. Employees receive education in Lean, Six Sigma, change management, and “Imagine 21” to create a better focus on goals and performance.

Physicians at Decatur often play the role of “consultant” at various stages and offer advice or input to specific processes. Using tools such as the Stakeholder or GRPI Analysis helps to determine whether a clinician needs to be involved and at what level—in other words, whether they will participate periodically, receive information on a “need-to-know” basis, or serve as the chief decision maker.

Since their deployment began, more than 50 Green Belts have been trained at Decatur, and every formal project has an internal Black Belt assigned to provide mentoring. A monthly review process helps to keep their efforts on track and includes executives, Six Sigma leaders, and others in the organization. “These reviews have become an important communication tool within the hospital,” says Don Miller, Master Black Belt at Decatur.

Decatur has also developed Yellow Belts who are trained in basic Six Sigma concepts and Lean techniques, and who focus on improving their individual work units. The combined methodologies are integrated into the fabric of the organization, and results are measured in terms of higher satisfaction, increased efficiency, and better service quality. While initially receiving outside help to get its programs started, the hospital is now able to manage its own internal training and projects.

The Nebraska Medical Center, Omaha, NE

The Nebraska Medical Center is a 690-bed hospital in Omaha that includes regionally and nationally recognized programs in cancer treatment and transplantation, neurology, and cardiovascular services. The hospital was formed by the merger of Clarkson Hospital and UNMC’s University Hospital in 1997. Although it had dealt with the complexities of joining two distinct cultures and maintained a performance improvement department, some frustrations had begun to arise due to lack of strategic focus in this area and recommendations not always being implemented.

As CEO at The Nebraska Medical Center, Glenn Fosdick always placed a strong emphasis on sustainable quality. Under his leadership, the hospital began a Six Sigma program in 2002, with specific goals to help the organization achieve measurable, sustained results that significantly improve its key processes, and advance its focus and commitment to continuous quality improvement.

“We have had quality initiatives for a long time in our organization,” Fosdick says. “Bringing the Six Sigma tools in allowed us to have a common approach to issues and has given us great strategic advantages. For a successful project, you need to improve outcomes, increase efficiency, or make somebody’s job easier. If all you’ve done is make someone’s job easier, it’s well worth the effort.”

As of August 2006, the status of the Six Sigma improvement program includes

• 44 DMAIC-Lean projects initiated

• 1 Manager, Six Sigma (Master Black Belt Trained)

• 2 Master Black Belts

• 5 Black Belts dedicated full-time to quality improvement projects

• 6 Trained Green Belts actively applying DMAIC and Lean Tools/Methods

The return on investment for The Nebraska Medical Center has been significant and exceeded the expectations of the hospital’s leadership team (see Table 8.3). “In addition to better quality results, the structure we’ve put in place is working well for us financially,” says Fosdick. “We haven’t laid anyone off for budget-related reasons for four consecutive years.”

Table 8.3. Financial Impact, Nebraska Medical Center (as of 11/05)

The organization continues to seek and adopt a variety of management best practices, and in 2006, The Nebraska Medical Center was recognized for service excellence under the J.D. Power and Associates’ Distinguished Hospital Program, acknowledging a strong commitment to provide an outstanding patient experience.

The approach draws interest from employees, who are identified and asked as high-potential future leaders to be part of the Six Sigma program. Jason Lebsack, Six Sigma Manager at The Nebraska Medical Center, noted that while the program requires a lot of work and dedication, they owe it to their patients to come as close to perfection as they can.

Keys to their continued success include creating a “quality umbrella” and integrating methods, having dedicated resources, building acceptance, and focusing on sustainability. Moving forward, the hospital’s plans include further integration of Lean and DMAIC tools, increased communication, and providing advanced change agent training in such topics as Lean Thinking, Project Management, and FMEA.