Six Sigma improves care, reduces hospitals’ costs

Projects reduce variation, create efficiency

Before Virtua Health instituted a Six Sigma project to improve its congestive heart failure program, the hospital system’s average length of stay (LOS) was 6.5 days, compared with the Medicare benchmark of 4.2 days. After a pilot project at one of the Marlton, NJ-based nonprofit health care provider’s four hospitals, the LOS dropped to four days with a savings of $116,000 per year in staff and room costs.

Virtua Health has improved patient care and generated literally millions of dollars of savings in its four hospitals by using Six Sigma, a strategic problem-solving approach to improving business operations. "If hospitals don’t consider ourselves a business, we’re going to be in trouble. With reimbursement declining, the only thing we can look to improve is the processes," says Richard P. Miller, president and CEO.

Six Sigma was developed by Motorola and has been used by industry to improve processes for years. General Electric has developed a Six Sigma program specifically for health care professionals.

In the congestive heart failure project, the Six Sigma team examined the processes and found a lot of variations in what happened during the latter part of the patients’ hospital stays and during the discharge program.

For instance, about a third of the time, echocardiograms were not on the chart when the physicians needed them. Patients and their family members generally expected a longer LOS, and the family members often weren’t prepared to take the patient home on the day of discharge. "We began by making the patients and family aware on Day 1 of the activities that would take place during the hospital stay and the likely length of stay," Miller says.

Telling people their family member is likely to be ready for discharge on the third day helps them plan ahead for taking the patient home, he adds.

The team created a brochure for patients, which explained the typical course of care for congestive heart failure patients and the expected LOS. It modified the flow of test results and created standard operating procedures for the nursing team.

The pilot project was conducted in one of Virtua’s four hospitals and has been rolled out at the other facilities. "The congestive heart failure project looked at all the processes from beginning to end and really streamlined what was happening, incorporating patient and family education into the process," Miller says.

As a result, more beds were free and revenue was enhanced, he adds.

Six Sigma looks at the processes in health care and reduces the variation, cuts the number of steps, and allows the provider to get to its goals quicker and more efficiently, Miller says.

"The mindset in health care has been that improving quality will cost more. In a typical manufacturing setting, an improvement in quality means lower cost. We have found that if we take the variation and fragmentation out of health care, it will result in a lower cost and better patient care," he adds.

Miller brought the Six Sigma process to Virtua Health in 2000 to support his STAR initiative, a five-pronged program to improve the patient experience. Components of the STAR are excellent services, employee satisfaction, clinical quality, caring culture, and resource stewardship. "I see Six Sigma as being a valuable part of a toolkit to improve patient care," he notes.

The hospital system has embarked on 40 major Six Sigma projects, creating upward of $2 million in annual savings, explains Mark VanKooy, MD, a Virtua Master Black Belt who oversees six full-time team project leaders along with Susan McGann, RN.

In the second year, the Six Sigma projects generated enough savings to pay for the original cost. Now, savings are running two to three times the annual cost.

Six Sigma is not necessarily a quality tool. It’s a business tool, and quality is one important part, VanKooy points out. For instance, one project involved improving reimbursements for carve-outs for implantable prosthetic devices in managed care contracts.

"The processes were breaking down. We weren’t capturing the new implantable devices and were not collecting from the insurance company," Miller says. As a result of the Six Sigma project, the hospital system was able to recapture close to $4 million the first year. "It had a huge financial impact," he says.

When the hospital considers a Six Sigma project, VanKooy and McGann look at all the stakeholders who will be touched by the project and decide how much each needs to be involved. Some may need just information; others need to be a member of the team because they are knowledgeable about the process. Still others may be called in as a resource only when they are needed. Case managers are part of the team in many projects, particularly those involving outcome improvement and moving patients through the continuum.

One part of the Six Sigma toolkit, called workout, encourages the team members to examine what caused processes to fail and to come up with steps to prepare for change ahead of time so initiatives will succeed. The exercise is followed by a one- or two-day brainstorming session that concludes with the development of action sets. Teams look at operational systems and discuss the reasons that problems occur. Then they focus on the biggest problems and what should be done about them. When the session is over, the team has developed an action plan to be implemented.

"It is action-oriented consensus building. One of the reasons it works is that in most meetings we spend 80% of the time discussing what we already agree on. This way, we understand why we disagree and come up with an action plan," VanKooy says.

A Six Sigma project is broken into five components: define, measure, analyze, improve, and control. Start by defining a process to improve, then measure how problems occur. Coming up with a valid measurement is a process that often takes a lot of work, he adds.

"Measuring systems in health care are often very weak. The most important thing is coming up with a gauging activity to see how well your systems measure," he explains. For instance, in one Six Sigma project, the leaders had the case managers review a set of charts to determine whether medications were given on time and whether any contraindications were noted.

The case managers agreed as little as 35% of the time. "We had reviewed the charts in advance and knew the answers. We determined that some of the information we were reporting to the Center for Medicare & Medicaid Services [CMS] which was ending up on the Internet as a reflection of our quality was inaccurate because of data collection errors and understated our actual performance, VanKooy says.

When the Six Sigma team met with the case managers to discuss the problem, it found the case managers never had been trained on how o gather the information needed for the CMS reports. They were given forms and told how to do it but weren’t told how to interpret ambiguous situations. When they worked on the problem, their agreement went to 85% to 90%.

"Once we fixed the measurement process, we determined that we had two serious problems: documentation of contraindication and when the proper medication is not administered or not prescribed," VanKooy says.

The team then started to look at why the problem occurred and who was accountable. It determined that a significant number of patients who were hospitalized for a myocardial infarction (MI) were not receiving aspirin within 24 hours as recommended.

Patients with an obvious MI got aspirin right at the beginning. It was the patients with the subtle symptoms who didn’t get the aspirin because their heart attack wasn’t diagnosed until the test results were complete, and they often missed the cutoff time established by CMS, VanKooy says.

The solution to the problem was totally unexpected, he adds.

The team looked at patient records and determined that most patients with an MI who didn’t get aspirin had shortness of breath. The team recommended that the paramedics give one aspirin to all patients with shortness of breath when it is clinically safe to do so. For instance, patients with asthma wouldn’t get an aspirin.

"We made sure we mistake-proofed it. It was a very successful intervention, and one that we never would have thought of without following the Six Sigma process. Our compliance went way up when we implemented that one simple thing," VanKooy says. The final phase, the control phase, is extremely important to the success of a Six Sigma initiative. "Other than not defining the problems appropriately, the biggest problem is to make improvements and not stick to them."

In the control phase, to assure long-term success, the process owner uses a reduced set of metrics to monitor deviations from the plan. "When the process starts to backslide, they detect it very early, and they know what steps to take," he says.

Six Sigma works on complex problems where there are steps you can take and a way to measure the results. For instance, Virtua tried to apply Six Sigma techniques to improve employee retention. "There are no specific steps you can apply to this process. It’s an important issue, but Six Sigma can’t work for it. It’s not for everything," VanKooy says.

(For more information on GE Healthcare’s Six Sigma program, see: