In 2001, Heritage Valley Health System (HVHS) began to look outside of traditional health care process improvement techniques to offset the issues facing many health systems regarding patient care and satisfaction, finance, retention and recruitment of staff and collaboration with physicians on clinical initiatives, to name only a few. Two improvement methodologies reached the final stage of evaluation, namely the Toyota Production System (TPS) and Six Sigma. Both methodologies were highly regarded by our staff but the operations team of HVHS decided on Six Sigma. The decision was made following lectures and demonstrations by TPS facilitators and Six Sigma facilitators.
The first critical issue facing our culture was, "How can an improvement methodology traditionally linked to manufacturing apply to health care?" Also, "How can we learn from Six Sigma improvement methodology experts who may not be well-steeped in the care of patients?" Just starting at HVHS after an extensive career in manufacturing with PPG, SONY and NOVA Chemicals, I was concerned that these issues would form substantial barriers to the deployment and implementation of the Six Sigma improvement methodology in a health care environment. To counter these barriers, we educated our executive leadership team on Six Sigma and decided to pilot a few projects prior to rolling it out across the system. Acting as the project team Black Belt, I facilitated a team whose charter was to evaluate the process of admitting patients into observation or in-patient status. Within one month, our admissions process improvement team identified multiple sources of lost revenue based on how patients are classified upon admission. More than one million dollars in revenue was captured and many internal processes were improved as a result of this first project. The effort from the beginning of this project to final staff education and process change took 7 months.
Our second project involved a study of Operating Room (OR) utilization. A team of four, meeting once per week for several months, identified that utilization of our ambulatory surgery center could be improved by transferring typical outpatient surgery from our hospital OR to the ambulatory facility. Outpatient surgeries include ear, nose and throat surgery, minor orthopedic surgery and cataract surgeries, for example. The extra capacity generated for the hospital OR was then filled with in-patient type surgeries where the revenue covered overhead cost. An additional outcome from this project included the redesign of a urology room, which led to avoiding the tandem scheduling of an additional room should the case require more extensive intervention. The extremely positive results of these short-term projects provided the proof the organization needed to understand that Six Sigma can truly be applied to health care situations.
The next step was to follow the plan established by the Six Sigma facilitators to train all leaders to the Champion level. During this training, the Senior Management team of HVHS spent 3 days getting a better understanding of the Six Sigma methodology and rollout strategy, through practical examples and actual process improvement experiments, demonstrating the power of Six Sigma and emphasizing the critical factors that must be controlled in order to successfully implement Six Sigma. We found this to be extremely important as the leaders developed a better understanding of the Six Sigma methodology and the multi-year plan of the organization to use Six Sigma to improve all aspects of our operation. Champions were taught how to identify projects, how to select Black Belt(BB) candidates and then how to support them through the project phases.
Failure Mode and Effects Analysis (FMEA) was a key problem identification and ranking technique that the Champions used to develop a project list. Potential projects were identified, then ranked using the categories of HR, IT, Finance, Quality and Market Growth and Expansion, our 5 strategic imperatives. At HVHS, Quality includes customer satisfaction, patient safety, employee safety and clinical outcomes as all efforts at HVHS are linked to and support one or more of the strategic imperatives. One critical issue that surfaced was that not all leaders participated in the development of the original project opportunity lists or BB candidate selection. At the start, we did not have in place a mechanism that held leaders accountable for their participation and this is desperately needed. However, the results of the leaders that fully participated in this original effort helped identify key opportunities for improvement and also provided the nominations of those who became our first BB candidates. We decided to move forward with the first wave of training and fix the accountability issue as soon as possible and most certainly prior to rolling out our second wave of training.
In August 2002, 8 months following the agreement to pursue Six Sigma, our first wave of students, 22 in all, were sent off campus for training. In concert with this effort, 2 half-day Six Sigma education sessions were provided to our board of directors and physician leaders. The objective was to have all HVHS leaders, physician leadership and board members understand and experience the Six Sigma methodology. The idea to include physician leadership and board members paid significant dividends as we presented progress reports on our Six Sigma implementation throughout the following year.
Another key learning from our first year was that students who are given 2 weeks of training (Black Belts typically receive more than 2 weeks of training) could make significant improvements on most projects. The Define, Measure, Analyze, Improve and Control (DMAIC) techniques, when taught with project examples, provide a powerful toolset to achieve gains in all areas of focus. The first two weeks of the HVHS program are designed to cover all 5 phases of the DMAIC methodology. These two weeks of training are separated by 5 weeks in order for the students to have time to apply the DMAIC methodology to their projects. The first week of training provides the foundational tools needed to identify issues, gathering data through the measure phase, and analyze the data for potential root causes of why the process performance measures may not be behaving as desired. The second week of training includes the improvement phase as well as understanding of project management and how to sustain the gains received from their efforts. Additional training, including Design of Experiments and other more advanced knowledge-gaining tools, are given to those who show a strong interest and capability to progress to the next level of process understanding.
Although it is very difficult to assign trained BB candidates full time to their projects, the dividends gained from full-time activity on their project work far exceed the returns one gets if they were part-time. At HVHS, we use a mix of part-time and full-time Six Sigma practitioners and found that works very well. We have learned that full-time allotment to project work typically results in rapid project completion, although several of our lesser-scoped projects were also completed fairly rapidly as a result of part-time project work. Part-time students were more likely, however, to encounter conflict in managing both a project and their normal work duties. Several part-time projects lagged behind the target of 6-month completion and tended to lose steam. Substantial project gains were identified on 86% (19 out of 22) of the training projects from the first wave of students.
A trained Six Sigma candidate does not receive a Black Belt designation at HVHS until the student and Champion can demonstrate a sustained gain from a project over a 6-12 month period. Our philosophy is that if one can show sustained gains over this period, the process change made is more likely to stick and to become part of normal practice.
The next phase of our work involved the physicians. A few clinical based projects, although delivering excellent detail on the issues surrounding a specific diagnosis, were not being accepted throughout our system. Using the idea of our chief medical officer and again partnering with the Six Sigma facilitators, we provided a 4-hour Six Sigma Continuing Medical Education (CME) 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, we requested physicians to partner with our project leaders, either in a mentor/advisor role or if desired, in a project leadership role. Now, every clinical project has a physician mentor or leader, where the physician is then the key contact to the medical staff, presenting findings at a peer level. Gains from this selected path were successful in our open-heart and cataract surgery projects and we are waiting to measure the outcomes in our heart failure, pneumonia and chronic obstructive pulmonary disease projects.
The overall objective of HVHS is to develop Six Sigma as a "Pull Process". Previous endeavors had all employees being trained in a given technique, only to find many employees disheartened by the process if they never were given a chance to work on improvement projects. Six Sigma is being taught and ingrained as a grow-from-the-sharing of successes. When a student closes a project, poster presentations are made, information is shared on their work during hospital week celebrations and formal recognitions are being planned. As other employees see and hear of this work, we are finding numerous cases of employees asking how they, too, can participate. Again, a pull process is believed to be better than pushing new methods at employees, and there is no better way to derive this pull than through the sharing of quickly obtained successes.
The cost of our 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 is not included in this number. Returns from our first year's effort far surpassed training cost in both financial gains, process improvements and gains in customer satisfaction and employee morale. Gains are tallied and reported to our organization and board of directors.
Because of the results from year one, the organization decided to expand our efforts in year two through partnership with other hospitals, increasing the number of projects and students selected for wave two training and to add full time staff as project leaders. It is true that health care workers desire training that is related directly to their issues. The inclusion of health care project successes during black belt training and allowing BBs to present their projects and results at subsequent training waves was well received. Establishing the organization plan as a foundation and communicating this plan during Champions training is key to a successful journey toward Six Sigma acceptance and implementation.
Who is Heritage Valley Health System
Heritage Valley Health System, formed in 1996, is a community based healthcare system. It encompasses The Medical Center, 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. Heritage Valley Health System 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. We are in partnership with more than 500 physicians.
Our mission in the system is to improve the health and well being of all the communities we serve. Our vision is to be the healthcare system of choice. We believe that our unique connection to our communities will help us achieve these goals.
Richard P. Beaver
VP, Quality - Heritage Valley Health System
rbeaver@hvhs.org
412-302-9900
Richard Beaver was appointed to the position of Vice President, Quality for Heritage Valley Health System in July 2001. He previously served as the leader of Operational Excellence and Quality for Nova Chemicals. Prior to working at Nova, Rick was employed by Sony Electronics as the leader of Operations, Manufacturing, Engineering and Maintenance. In both positions, Rick developed an expertise in 6 Sigma and other continuous improvement techniques that he is helping to integrate into HVHS and to apply toward improvements in the care of our patients and visitors.
Rick earned a B.S. in Chemistry at the University of Pittsburgh in 1978 and continued his education with graduate work in polymer chemistry at Carnegie Mellon University. He also completed leadership training at the Center for Creative Leadership and obtained his "Black Belt" in Six Sigma techniques at SONY and NOVA Chemicals.