Nearly everyone agrees that quality healthcare is a good thing. But few can actually define it or know how to measure it. What exactly is quality, how can it be measured, and what does it cost? More importantly, how much quality is enough?

Quality Performance Measures

The previous article in this series¹ described two quality process measurement methods used widely in industry—dynamic benchmarking and balanced scorecarding. Briefly, dynamic benchmarking is measuring performance against quality standard indicators—concurrently, in real time. The knowledge gained from real time information is valuable because variances can be acted upon immediately, before the behavior that caused a problem is ingrained, and damage control becomes a daunting prospect.

Balanced scorecarding, also dynamically implemented, is an expanded form of traditional benchmarking that explores and continually evaluates four interrelated areas of operational and clinical performance: patient and client satisfaction, staff satisfaction, process performance and service quality, and financial performance. Traditionally, performance was measured by evaluating financial factors exclusively. Balanced scorecarding uses a much broader view. An aircraft control panel is a commonly-used analogy for balanced scorecarding. Airplane pilots who rely only on the gas gauge limit their knowledge about how well the plane is performing. If the pilot has no knowledge of current speed or altitude, for instance, disaster will surely ensue.

The same is true for product and service businesses. All aspects of operational performance must be frequently scrutinized to continually evaluate the organization’s position. Regular examination of performance data and analysis of how processes affect patients, clients, and staff helps managers intervene and correct substandard processes, thereby improving quality. This article will examine a third advanced quality measurement approach known as Six Sigma, an extraordinarily precise quality improvement tool.

Six Sigma

Six Sigma is a data-centered methodology for improving process quality that has been proven in industry and is increasingly being implemented in healthcare. The Six Sigma approach makes quality measurements highly quantifiable, with a goal of near perfection in the delivery of products and services. In fact, when Six Sigma is achieved, fewer than 3.4 defects are found in one million opportunities—very close to perfection indeed!

Sigma is the Greek letter that represents the standard deviation of data about a normal distribution curve—the outward distance from the center or highest point of the curve. If a process is centered on target performance, then sigma portrays the amount of variation from desired performance. The higher the sigma level for a process, the more in control it is, and the closer the performance is to perfect (error free). Most performance, regardless of the activity or industry, falls within the two sigma range, which represents 308,537 defects per million opportunities. Using Six Sigma tools to measure performance, managers can accurately gauge how near to perfect their processes are now.

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Originally developed at Motorola, Six Sigma became widely known through Jack Welch, former CEO of General Electric, who was extraordinarily successful using the method to create efficiency and increase profitability at General Electric. The GE success story has been told by Jack himself in his autobiography and lectures, and recounted in scores of other books about Six Sigma.

Applied correctly, Six Sigma is a powerful and effective performance measurement tool. With total commitment at the highest executive level, it can be applied with great success in healthcare. The process is simple to understand, but often complex to implement. The basic approach has the acronym DMAIC:

• Define—define the problem or quality goal that will be addressed.
• Measure—measure what you care about. Don’t waste time with superfluous data tracking.
• Analyze—statistically find the root causes of errors and problems using the data. Design solutions that are feasible and will likely solve the problem.
• Implement—infuse the solutions into operations and measure results.
• Control—use data tools that will monitor and sustain the improvements and desired results.

DMAIC is a familiar and logical process, but the challenge is in the details. To achieve near perfect performance, significant changes in behavior and assumptions are required throughout the organization. If current error rates are considered "normal" or "just the way things are," improvement is unlikely. Problems and root causes must be carefully studied and defined, and only the ones with the greatest opportunity to reduce risk or improve results should be targeted. Selecting an effective and high-level leader with a long-term commitment to the project is imperative. Most organizations seeking quantum improvement employ a consultant who specializes in Six Sigma methodologies to educate participants and help the team through the process.

Six Sigma uses data for analysis, therefore the project design includes defining how data will be collected, from where, and by whom. Accountabilities must be established and processes documented electronically.

An example of a very successful Six Sigma project in healthcare is that of Morton Plant Hospital Emergency Department in Florida.² Accomplishments included the following:

• improved patient satisfaction more than 50%, from 61% to 95%;
• decreased length of stay by 21% in the ED and 61% in Express Care;
• decreased LWOTs (left without treatment) from 3.9% to below 0.5%, from a high of 212 to a new low of 7;
• recovered more than $4 million in cost of quality due to LWOT reduction alone.

While this example reflects activity in a busy emergency department and urgent care center, the indicators monitored apply just as well to occupational health clinics. Six Sigma measures can be sized to occupational health volume. The preceding results clearly reflect a high degree of performance monitoring, measurement, and documentation. One can only conclude that the organization considered saving $4 million while improving patient satisfaction by 50% was worthy of the energy and resources applied.

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Implementing the Plan

When the decision is made to commit to quality, determine what will constitute success. Six Sigma may be too aggressive an approach as a starting point, but its formula for perfection can be set as a guide. Morton Plant ED’s goal for improving patient satisfaction by a factor of X% is very specific and measurable, and upwardly progressive over time.

Select a measuring tool, such as electronically documented patient audits, and measure present patient satisfaction first to establish a baseline performance level. Then define actions and interventions to generate improvement.

Assign individual accountability for collecting the data. Quality control projects are frequently sidelined by staff who say they do not have time to collect the necessary monitoring data. In fact, reluctance to enter data, from the physician through the entire staff, can be the greatest stumbling block to proving and improving quality.

Quality improvement is a process that requires new staff behaviors. By continuing to measure patient satisfaction and providing staff with immediate feedback about their progress, the appropriate behaviors of the team are reinforced. Frequent and consistent information exchange with staff members to communicate current patient satisfaction levels provides a barometer of success and encourages continued positive action. Concurrent information feedback can modify behavior!

Commitment to quality measurement must be led and sustained by top management. The purpose and vision for the project must be clearly communicated and consistently championed. Without involvement at the highest level, quality performance projects fizzle, dragged down by the busy, task-oriented nature of the core business.

Not surprisingly, the process of improving quality and developing "proof of quality" metrics is not without cost. Whether it’s the powerful tools of Six Sigma, dynamic benchmarking, balanced scorecarding, or simple internal activity monitoring that you select as your method, resources are necessary to achieve quality improvement goals. Resources include both human and electronic systems, and both must be applied with creativity, enthusiasm, and tenacity.

Remember, the cost of quality is small compared to the efficiency, customer loyalty, and recovered dollars that even modest efforts will generate. The flip side of the cost-of-high quality coin is the cost of low quality. Perpetuating errors, redundancy, re-work, or simply annoying patients, clients, or other stakeholders carries a very high price tag—lackluster financial performance and the slow demise of the business. Refuse to be a victim—budget for quality improvement and experience the benefits!

Resources

http://www.ge.com/sixsigma

http://gess.ge.com/sigma.asp

http://www.gemedicalsystems.com/prod_sol/hcare

Footnotes

1 Wolfe, K., "Competitive Edge: Providing Quality Care—and Proving It," Occupational Health Tracker, Vol. 6, No. 1, Spring, 2003.

2 Caldwell, C., Johnson, L., Cook, B., Moran, D., "ER Six Sigma effort results in 50% satisfaction improvement and $4 million cost recovery, Part I," HealthLeaders News, January 17, 2003.