Six Sigma Takes Root at North Carolina Baptist Hospital

by Annette Wilkerson Porter

from Visions, Fall/Winter 2005

Six Sigma process improvement methodology empowers employees to redesign workflow for optimal outcomes, efficiency, safety and savings. It’s a win-win approach that’s making headway across N.C. Baptist Hospital.

The Six Sigma process improvement deployment at North Carolina Baptist Hospital is starting to show the kind of results that convert skeptics to believers.

Consider:
A Six Sigma process improvement team charged with getting heart attack patients from the Emergency Department into the cardiac catheterization lab for treatment faster slashed 41 minutes off the hospital’s mean time — beating the goal set by the American College of Cardiology.

A Six Sigma team focused on improving throughput of patients in Cardiac Ultrasound and Stress Testing was able to increase the number of procedures performed each day using the current level of staff and equipment — avoiding additional expenditures of more than $200,000 a year.

Another team, challenged to speed the time from referral to admission for inpatient rehabilitation beds, cut nearly two days from the process.

The Six Sigma process improvement methodology is still in its infancy at NCBH, but already there are more than 30 projects underway, with teams applying process analysis techniques to deliver breakthrough improvements across the hospital.

Most Six Sigma projects have quality of care and financial goals. Every project is designed individually to address an identified problem or opportunity, from faster bill collection, improved equipment utilization and on-the-job injury prevention to improvements in clinical service and reductions in length of stay.

When a project is identified — or scoped, to use the Six Sigma terminology — representatives of each area involved in the task meet with a Six Sigma-trained leader to map the process at hand. Using the Six Sigma DMAIC methodology, the team will define, measure, analyze, improve and finally control the processes. These steps usually take about four months, after which gains are tracked and monitored with a Web-based project tracking software called ProjX.

“Six Sigma process improvement methods can be applied to any area of the hospital,” said hospital Vice President of Operations Steven C. Snelgrove, who serves as the NCBH Six Sigma Executive.

Six Sigma was developed in the late 1980s by Motorola and widely embraced in the manufacturing sector — notably by General Electric — because of its proven ability to improve productivity and cost control and reduce process variation.

NCBH introduced the program in April 2004, amidst the first wave of hospitals to adapt this scientific methodology to improve all aspects of health care delivery.

Hospital President Len B. Preslar Jr. had sounded the call several years ago to bring a process improvement methodology to NCBH.

“Just cutting cost or budgets is easy, but it creates a strain on those providing services, may compromise quality and may not be sustainable over time,” says Preslar. “But changing how we conduct our business in a manner that standardizes the process around a best practice enables lower cost as a by-product, even as it improves customer service quality. Doing it right — the first time, every time — is more effective and efficient.”

Preslar assigned a leadership team to research Six Sigma and other types of process management. The group determined that Six Sigma was the most robust approach available, the one that would “drive our organization to even higher levels of excellence in cost, quality, service and culture,” says Preslar.

“Six Sigma teaches and applies the fundamentals of process improvement which recognize that any process or outcome is a function of certain variables … outputs equal inputs or Y=f(X). So if you can identify all the critical variables that can affect an outcome and learn how to control them by eliminating variation in how they are performed, then the outcome is very predictable,” explains Snelgrove.

Six Sigma is not the first effort NCBH has made to harness process management and improvement, but Snelgrove says it’s different from other approaches because “we are able to make it our own and embed it into operations with just a little reliance on outside consultants. NCBH’s senior leadership team spent three days writing the policies and procedures concerning how Six Sigma process improvement would be applied and managed here. Those policies can be found in an on-line employee Six Sigma eHandbook. There is also an unprecedented level of commitment to internalize Six Sigma into our organizational culture.”

One sign of that commitment is the dedicated team created to carry out the Six Sigma deployment.

NCBH has built and trained a force of Six Sigma leaders — whose titles borrow from the martial arts vocabulary — currently including two Master Black Belts, 11 Black Belts and 34 Green Belts, to spread the methodology through every level of the hospital. NCBH retained Breakthrough Management Group to help launch the program and provide the first wave of training.

Black Belts are full-time Six Sigma leaders and facilitators who have been recruited from within NCBH ranks and from other industries. They are each expected to identify and complete four to six projects annually, with an average financial goal of $100,000 hard savings per project.

Green Belts carve out 20 percent of their regular hospital work-time to lead qualified Six Sigma projects, which are each expected to save $25,000 per project. They are effectively “change agents” within their work areas. By next spring, NCBH will have trained a total of 54 Green Belts, amplifying the Six Sigma process improvement approach.

At the helm are two Master Black Belts, Er Ralston and Debbie Hunter, process improvement experts who are orchestrating system-wide penetration of the Six Sigma approach.

Ralston said, “Our vision is that Black Belts will eventually be embedded in each division so that they become a key resource for divisional vice presidents to execute strategic improvements.” The NCBH plan calls for most divisions to have a dedicated Black Belt within a year.

Over the summer and fall, hospital vice presidents and directors participated in Six Sigma training so that they can identify projects and integrate process improvement into their areas of responsibility. VPs are called “Champions” and directors are “Process Owners” in the Six Sigma lexicon.

Ultimately, all employees will be fluent in the Six Sigma vocabulary and process, thanks to ongoing internal training.

That vocabulary starts with “DMAIC,” an acronym for the five steps involved in carrying out a Six Sigma process improvement project:

1. Define the problem and project parameters and establish an improvement objective.
2. Measure each of the process steps involved, determine which will be the focus of analysis, collect data.
3. Analyze the collected data to test hypothesis about key process factors.
4. Improve by establishing a pilot to test and measure improved process.
5. Control by implementing the process improvement and continuously monitoring that gains are held.

Six Sigma leaders envision the day in a not-too-distant future when DMAIC will be common parlance among employees.

“It will simply be the way things get done,” says Ralston.

Snelgrove notes that with Six Sigma process improvement, problem-solving occurs in a key way on the “worker” level. “This is not about the top layers forcing change,” he says. “This approach acknowledges that the people who are doing a job are the experts, and they are the ones who will drive improvement.”

The Six Sigma methodology helps problem-solvers overcome assumptions — myths — that often get in the way of solutions. The approach includes an actual deconstruction of the steps of any procedure so that the team can analyze them and create a metric to measure validity of assumptions.

Another great strength is that the approach, by definition, brings together all of the “players” in a process — people who may never have directly communicated about the process before because the processes typically cross departmental lines.

Janice Gasaway, one of the hospital’s first Black Belts and the former associate director of nursing in cardiology, led a project that crossed over eight departments: the Rehab Referral to Admission project that trimmed two days from referral to inpatient rehabilitation admission.

“This is one of the strengths of Six Sigma’s approach,” she says. “We don’t typically bring all the players together in one room and discuss how the actions in one area impact others. When a problem is identified, the whole objective is to try to make the process better for everybody. This is really an opportunity for people to reinvent the way they do things to make them more successful.”

In the first stage of working with a team, Gasaway notes that people are often apprehensive, sometimes defensive. “Some people start off as skeptics. They’re resistant to change. You come at this from the perspective that an opportunity for improvement has been identified, and it’s about processes — not about the people.

“The beauty of this process is that when you can show the data you have collected, it’s usually pretty clear where the problems are,” she says. “So people who had strong ideas about what the problem was can see if the data supports their view or not. That’s when even the biggest doubters come around — when the data disproves their opinion.”

The “Door to Balloon” project that involved getting heart attack patients quickly from the ED to the cardiac catheterization lab for treatment is another example of effective multidisciplinary communication.

Kathy-Ann Wells, the Green Belt Cardiac Cath lab nurse who led the project, said it was the first time that staff in the three departments involved — the Emergency Department, Cath Lab and the Physician’s Access Line (PAL^®) — had ever met to discuss their challenges. “They worked together to clarify how the process should work, then implemented a number of improvements in all three areas that not only met the challenging national goal, but showed they could surpass it.”

Black Belt James Sidden led the Cardiac Ultrasound throughput project, an effort that began with a focus on reducing procedure time in order to accommodate growth in demand. As the team began analyzing data, they discovered that the problem was not the cycle time per se, but actually stemmed from scheduling and patient flow. Procedures were bunched up in the middle of the day, causing late work days for staff and stressful waits for patients.

Sidden’s project included echo technicians, RNs, cardiac stress techs, transporters, support staff and the medical director. They analyzed every element of the patient process, from appointment reminder calls to staff pages to start times for transport teams. Solutions included staggered start times for transporters to ensure that patients were available for the first morning time slots, and a revised flow for non-patient work activities. With the improved flow, the group was able to add a procedure to the daily calendar without adding the assumed stress of “more work.”

“The results include improved service and avoided labor and capital equipment costs for fiscal year 2006,” says Rich Lundy, administrative director of cardiology diagnostic services. Another benefit should include improved staff and physician morale as after-hours procedure scheduling requirements are reduced.

James Hoekstra, M.D., professor and chairman of the Department of Emergency Medicine, attests to the benefits of Six Sigma process improvement methodology. He participated in a project to reduce turnaround time in the Fast Track of the Emergency Department.

“The process looked critically at each step in a patient’s progress through the department and analyzed each step in order to improve the turnaround time,” explains Hoekstra. “Each process change which was implemented resulted in small changes in turnaround time. When the total process was mapped, the total change in turnaround time was palpable.

“In addition, just the process of Six Sigma itself brought about behavior changes in nursing, ancillary and physician staff. Measuring outcomes incentivizes staff to improve processes and patient throughput. This was evident in the fact that turnaround time improved even before any process changes actually occurred. The staff knew they were being analyzed and responded by improving their efficiency,” Hoekstra says.

Snelgrove says, “Identifying who the Process Owner is and assigning them accountability for measuring outcomes, communicating the results back to staff and holding the gains creates an incentive for staff to do their best.”

Just about everyone who has worked with the Six Sigma process has seen “a-ha” moments when the team breaks down the elements of a task.

“As people are defining a process or a problem, sometimes solutions emerge in that moment, in the detail of their description, they’ll see where something doesn’t really make sense,” says Sidden. “This process makes you evaluate each step and then methodically analyze data. You wind up overturning commonly held assumptions when you are faced with hard data that shows otherwise. You’re disproving myths to uncover solutions.”

The Six Sigma approach is very much one of learning by doing, and team leaders have learned a lot in the first year of deployment. For one, they have learned how to better define manageable and measurable projects. Many projects initially approved were too global in scope and so could not be accurately measured with process data. The teams have also learned to better hone their financial goals.

“We’ve learned to refine and narrow our projects, which means we can get in and show results faster,” says Snelgrove. “You want to be able to get in, complete the project within three to four months and get out — and then keep monitoring the results with our new ProjX software to make sure the gains are held.”

Er Ralston, who has built his career on process improvement in a variety of settings, sees NCBH as fertile ground. “This organization is very receptive — the openness is definitely there to try this, and the commitment is there at the executive level. When you have a leadership team that is behind you and people who are ready and willing — then the fun comes when you see projects come to fruition and success.”

Fruition and success translate to improvement in both quality of care and return on investment, which Snelgrove expects over time to be as much as a three-to-one return on the salary and training costs. “That’s the ROI demonstrated in other organizations,” he says.

NCBH President Len Preslar is enthusiastic about Six Sigma’s future and is committed over the long haul. “Changing culture takes time, so the results will evolve and accelerate over time. But the results are promising and I am confident we will accomplish our goals.”