by Richard Beaver

In 2001, Heritage Valley Health System began to look beyond traditional health care process improvement techniques to offset the issues facing it and many other health care organizations. Some of these issues were patient care and satisfaction, finance, staff retention and recruitment, and collaboration with physicians on clinical initiatives.

Two improvement methodologies, the Toyota Production System and Six Sigma, were reviewed and highly regarded by the staff, but the HVHS operations team ultimately decided to develop a Six Sigma program. The decision was made following lectures and demonstrations by TPS facilitators and facilitators from Air Academy Associates, the firm with which HVHS partnered to roll out Six Sigma.

The most critical question facing the organization was, “How can an improvement methodology traditionally linked to manufacturing apply to health care?” A related and frequently voiced concern was, “How can we learn from Six Sigma experts who might not understand patient care?”

Because Six Sigma is generally associated with manufacturing, there was concern that the deployment and implementation of the improvement methodology in a health care environment wouldn’t work. To address this concern, HVHS educated its executive leadership team on Six Sigma and piloted a few projects prior to rolling it out across the system.

One Black Belt team was charged with evaluating the patient admission process to observation or inpatient status. Within one month, the admissions process improvement team identified multiple sources of lost revenue based on how patients were being classified upon admission. More than $1 million in revenue was captured, and many internal processes were improved as a result of this first project. The effort, from the initial project meeting to final staff education and process change, took seven months.

The second project involved a study of operating room utilization. A team of four, meeting once a week for several months, identified that use of the organization’s ambulatory surgery center would improve by transferring typical outpatient surgeries (e.g., for ear, nose, throat and minor orthopedic problems, and cataracts) from HVHS’s operating room. The extra capacity generated for the hospital operating room was then filled with inpatient-type surgeries, where the revenue covered overhead cost. An additional outcome from this project included a redesigned urology room, which helped the hospital avoid tandem scheduling of an additional room in case more extensive intervention was required.

The positive results of these short-term projects provided the proof the organization needed to understand that Six Sigma could indeed be applied to health care situations.

The next step was to train all leaders to the Champion level. During this training, HVHS’s senior management team spent three days familiarizing themselves with the Six Sigma methodology and rollout strategy. Practical examples and actual process improvement experiments demonstrated Six Sigma’s effectiveness and emphasized the critical factors that must be controlled in order to successfully implement it. HVHS leaders developed a better understanding of Six Sigma methodology and the organization’s multiyear plan to use the methodology to improve all aspects of its operation. Champions were taught to identify projects, select Black Belt candidates and then support them through all project phases.

Failure mode and effects analysis was a key problem-identification and ranking technique the Champions used to develop a project list. Potential projects were identified and then ranked using five strategic imperatives: human resources, information technology, finance, quality and market growth, and expansion. At HVHS, quality comprises customer satisfaction, patient and employee safety, and clinical outcomes. All efforts at HVHS are linked to and support one or more of these strategic imperatives.

One critical issue that surfaced was that not all leaders participated in developing the original project or selecting Black Belt candidates. At the start, HVHS didn’t have a mechanism in place that held leaders accountable for their participation, and this was desperately needed. However, the results garnered from leaders who fully participated in the original effort helped identify key opportunities for improvement and also provided nominations of those who became HVHS’s first Black Belt candidates. The organization moved forward with the first wave of training and fixed the accountability issue before rolling out its second wave of training.

In August 2002, eight months after the decision to pursue Six Sigma, 22 employees were sent off campus for training. In concert with this effort, two half-day Six Sigma education sessions were provided to the board of directors and physician leaders. The idea to include physician leadership and board members paid significant dividends, as evidenced by progress reports on Six Sigma implementation throughout the following year.

Another important discovery from the first year was that students who were given two weeks of training (Black Belts typically receive more) could make significant improvements on most projects. Define-measure-analyze-improve-control techniques, when taught with project examples, provided a powerful toolset to achieve gains in all areas of focus. The first two weeks of the HVHS program are designed to cover all five phases of the DMAIC methodology. The first week provides the basic tools needed to identify issues, gather data through the measure phase and analyze them for potential root causes of process performance problems.

The second week--which occurs after a five-week period during which students apply DMAIC methods to their projects--includes the improvement phase as well as understanding project management and how to sustain the gains received from their efforts. Additional training, including design of experiments and more advanced knowledge-gaining tools, were given to those who showed a strong interest and capability to progress to the next level of process understanding.

Although it’s difficult to assign trained Black Belt candidates to their projects full-time, the dividends gained from full-time activity far exceed the returns from part-time efforts. HVHS used a mix of part-time and full-time Six Sigma practitioners and found that worked well. Full-time allotment to project work resulted in rapid project completion, although several projects were completed fairly rapidly by part-time students. However, these students often encountered conflicts in managing both a project and their normal work duties. Several part-time projects lagged behind the six-month completion target and tended to lose steam. Despite the issues with longer project lead time, substantial project gains were identified on 86 percent (19 out of 22) of the training projects undertaken by the first wave of students.

At HVHS, a trained Six Sigma candidate doesn’t receive Black Belt designation until the candidate and Champion can demonstrate a sustained gain from a project over a six- to 12-month period. The philosophy is that if the team can show sustained gains over this period, the process change is more likely to stick and become part of normal practice.

The next phase of work involved physicians. A few clinical-based projects, although they delivered excellent detail on the issues surrounding a specific diagnosis, weren’t gaining acceptance throughout the system. Using ideas from the chief medical officer and again partnering with Air Academy Associates, HVHS provided a four-hour Six Sigma Continuing Medical Education class for physicians. Physicians commented that the Six Sigma methodology was easy to understand, and they liked the technical, measurement-based philosophy.

As an outcome of this class, HVHS requested physicians to partner with project leaders either in a mentor/advisor role or, if they were willing, in a project leadership role. Today every clinical project has a physician mentor or leader. The physician is the key contact to the medical staff and presents findings at a peer level. Gains from this process are apparent in HVHS’s open-heart and cataract surgery projects, and results are pending in heart failure, pneumonia and chronic obstructive pulmonary disease projects.

HVHS’s overall objective is to develop Six Sigma as a “pull process.” With previous endeavors, all employees were trained in a given technique, but many became disheartened by the process if they weren’t given a chance to work on improvement projects. Six Sigma is becoming ingrained as it grows from sharing success stories. When a student closes a project, poster presentations are made, information about the project is shared during hospital week celebrations, and formal recognitions are planned. As other employees see and hear of this work, participation grows. A pull process is better than pushing new methods at employees, and there’s no better way to derive this pull than by sharing information about quickly obtained successes.

The cost of HVHS’s first year of training was $123,000, including only external costs for educators, supplies, software and training facilities. Some of the education was developed and provided internally. Student training time isn’t included in this number. Returns from the first year’s effort far surpassed training cost in terms of financial gains, process improvements, and gains in customer satisfaction and employee morale. Gains are tallied and reported to the organization and board of directors.

Because of the results from the first year, the organization has decided to expand its efforts by partnering with other hospitals, increasing the number of projects and students selected for the second wave of training, and adding full-time staff as project leaders.

Health care workers desire training related directly to issues that matter to them. It’s imperative to include health care project successes during Black Belt training and allow Black Belts to present their projects and results at subsequent training courses. Establishing the organizational plan and communicating it during Champion training is key to a successful journey toward Six Sigma acceptance and implementation.

About Heritage Valley Health System

Heritage Valley Health System, formed in 1996, is a community-based health care system located in Western Pennsylvania. It encompasses The Medical Center in Beaver, Sewickley Valley Hospital, 49 physician offices, the Moon Surgery Center and 14 community satellite facilities that offer rehabilitation, lab work and occupational medicine. Heritage Valley Health System is the fourth-largest health system in Western Pennsylvania. It provides comprehensive health care for more than 300,000 residents of Allegheny, Beaver, Butler and Lawrence counties in Pennsylvania, eastern Ohio and the panhandle of West Virginia. HVHS is in partnership with more than 500 physicians.

The organization’s mission is to improve the health and well-being of all the communities it serves.

About the author

Richard Beaver is vice president of quality for Heritage Valley Health System. He has served as the leader of operational excellence and quality for Nova Chemicals Inc. and led operations, manufacturing, engineering and maintenance at Sony Electronics Inc. He’s also completed leadership training at the Center for Creative Leadership and obtained Six Sigma Black Belt status at Sony and Nova Chemicals under the curriculum and mentoring of Air Academy Associates. He would like your comments regarding this article, e-mail him at rbeaver@hvhs.org or call him at (412) 302-9900.