August 2005

www.asq.org/sixsigma

Lean-Six Sigma, Healthcare, and the Senior Leader’s Nondelegable Role

by Noel Wilson, ASQ staff writer

As a consultant and coach to senior leader teams, Black Belts, and physician leaderswho are learning to use improvement approaches like Lean and Six Sigma inhealthcare, Chip Caldwell also takes on the role of translator. “Any quality systeminvolves a lot of jargon,” he says, “so the first thing we do is read a three-page glossaryof terms.”

Caldwell, president of Chip Caldwell & Associates and coauthor of the newly publishedLean-Six Sigma for Healthcare, recently spoke with the ASQ Six Sigma Forum aboutimplementation issues surrounding Lean and Six Sigma in healthcare. Emphasizing aneed for active senior leader involvement and the integration of processes across anorganization, he identified success strategies, beginning with the importance of effectivecommunication.

Communicating Lean-Six Sigma in Healthcare

Translating a Lean and Six Sigma vocabulary into a language healthcare workersunderstand is the first step toward illustrating how the two improvement approachesapply to the work they do. Once healthcare workers see that Lean and Six Sigmaconcepts already exist in their own world, simply under different names, implementationbecomes easier. Almost all healthcare quality and productivity problems can beattributed to one of two categories—bottlenecks and throughput issues and errors,waits, and delays. These two types of quality problems are effectively solved through asenior leader-driven Lean-Six Sigma effort.

Explaining Lean — Healthcare’s current connection with Lean, says Caldwell, isparticularly strong: “Over the past two years in healthcare, there has been an intenseeffort to improve throughput and flow in response to overcrowding and capacityconstraints. In fact, hospital accreditation standards require documentation of whathospitals are doing to improve throughput and flow.” Introducing Lean effectively is thusoften a matter of discussing it in terms of throughput.

Explaining Six Sigma — Six Sigma’s vocabulary doesn’t come quite as naturally tohealthcare workers. For instance, Caldwell has learned that using the common SixSigma term “defects per million opportunities” can be a communication mistake in thepresence of healthcare senior leaders: “For some, ‘defects per million’ does not seemrelevant to their work, or they reject the idea of classifying errors as defects.” He has

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more success when he speaks in terms of “errors” or “bottlenecks,” or when he usesspecific examples of a particular type of error.

Although overcoming communication boundaries is crucial, implementing Lean-SixSigma is obviously more than a matter of simple translation. Caldwell points out thatusing terminology to establish common ground should not give the impression that ahealthcare Lean-Six Sigma initiative is like any other initiative in any other industry. Toensure the chances of success, implementation leaders must understand what makeshealthcare different.

How Is Healthcare Different?

According to Caldwell, the most important difference between healthcare and non-healthcare implementations is the role the senior leader plays. While it’s usually truethat active engagement of leadership will enhance any Six Sigma implementation, thesenior leader’s role becomes especially critical in healthcare.

“Black Belts can be deployed much lower in the organization in non-healthcareapplications,” says Caldwell. For a healthcare implementation to be successful,however, senior leaders have to accept day-to-day ownership.

Caldwell identifies two reasons that make the senior leader’s role particularly critical inhealthcare:

1. The role of physicians must be integrated for a healthcare application to besuccessful, and senior leaders are the integrators of physician processes.

2. When deployed below the senior leader level, Six Sigma projects have a tendency tobecome tactical. That is, they proceed on a project-by-project basis without workingtoward clear, overall objectives. Tactical deployment, as opposed to strategicdeployment, is a true failure factor.

Ultimately, Caldwell maintains, to ensure that an implementation avoids a tactical focus,leaders must treat deploying Lean-Six Sigma as a “nondelegable” role.

The Three-Year Magic Moment Approach to Projects

Conventional tactical approaches to selecting and scoping projects focus on solvingspecific problems. Teams identify a problem and then launch a project to uncovercauses and implement solutions.

Caldwell, however, teaches an approach that places individual projects in a largercontext of systemic improvement. Long-term targets, which he calls “three-year MagicMoments,” as opposed to problems, serve as the reasons for conducting projects.

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He outlines three steps to using the three-year Magic-Moment approach:

1. Three years from now, what results would you like to see? Identify a measurablegoal you want to achieve, establishing a target metric—25% improvement inemergency department length-of-stay, for example.

2. Which senior leader owns this Magic Moment goal? Find a senior leader who willaccept ownership of and manage the project work that will realize the goal.

3. How many projects will it take to reach the goal? Consider not only the core processor department associated directly with the goal, but other related processes as well.For instance, are hiring and staffing solutions needed? Will new or existingtechnologies need to be incorporated or implemented? Manage individual projectsand improvements so they contribute to the achievement of the Magic Moment.

Example: Approximately 20% of a hospital’s discharged patients go home by 2:00pm. Understanding that the time of day discharged patients leave has enormousimpact on overall throughput, a hospital wishes to focus an improvement effort on“time of day.”

The tactical approach:• The hospital launches a project to identify and implement a process

improvement.• The hospital reviews project results to determine whether improvement occurred

or another project is needed.

The Magic Moment approach:• The hospital identifies a long-term target. The “Magic Moment” will be reached

when 80% of patients go home at 2:00 pm.• The hospital assigns a senior leader to own the target.• The senior leader determines a number of projects throughout the organization

that will help the hospital reach its goal over the next one to three years.

The first project launched in the tactical approach may identify an improvement thatbrings results. The risk, however, is that the solution will not be systemic. “A tacticalapproach really attacks subprocesses, not the system,” says Caldwell. “This approachto finding solutions is like throwing wet noodles at a wall to see which ones stick.”

Integrating Projects and Processes

An advantage of the Magic Moment approach is that it emphasizes theinterrelationships of different functions within an organization. A Magic Moment itselfshould focus on a strategic area; all of the organization, however, can be involved in theprojects selected to help achieve the Magic Moment. As Caldwell says, “Projectsintegrate everything an organization does for a particular core process to get to theMagic Moment.”

Where can hospitals find the best opportunities for Magic Moments that are certain tointegrate processes?

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Caldwell identifies five highly strategic areas:

1. In the emergency department (ED), particularly addressing length ofstay/throughput, and the interfaces between the ED and the rest of the enterprise.

2. In the surgery, addressing capacity optimization. This Magic Moment is bestmeasured by “cut to close” hours divided by staffed hours.

3. On nursing floors (or patient floors), improving patient care throughput. Asmentioned above, the most appropriate metric for this Magic Moment is thepercentage of patients discharged by 2:00 pm.

4. In the clinical practice domain, length of stay and percentage adherence toestablished evidence-based medicine serve as the most effective strategicmeasures.

5. And perhaps the most impactful addresses staff productivity as it relates to quality.The best Magic Moment metric is the percentage of “In Quality” staffing levels. ThisMagic Moment alone drives quality upwards while recovering millions in cost ofquality.

For most hospitals, these areas represent what Caldwell refers to as “the five leverpoints.” The emergency department, surgery, and nursing floors may contain the “vitalfew” opportunities for improvement, but they also have hundreds of interfacesthroughout hospitals. Every employee at every level can have a role in Lean-Six Sigmaimprovements when the focus begins with these levers.

Deploy from the Top Down for Real Results

The integration of projects, processes, and employees under the Magic Momentapproach makes senior leader involvement all the more crucial. Senior leaders not onlymust own individual Magic Moments and identify projects to achieve them, but they alsomust actively and continually steer the overall implementation, ensuring that the rightMagic Moments are pursued at the right time.

At the beginning of a deployment, a hospital’s senior leaders must:

• Come together formally as a senior leader team.• Determine Magic Moment goals for the organization and synergize collective Magic

Moments.• Plan the training and deployment of Black Belts.

Active engagement of senior leaders from the beginning of a deployment ensures astrategic focus on the most influential process lever points and on one other importantfactor that, Caldwell states, healthcare staff often neglect—dollar results.

According to Caldwell, “Senior leaders understand that if the hospital’s core processlevers are improved, the exhaust will be cost recovery.” Below the senior leader level,however, healthcare leaders tend to shy away from cost reduction. Physicians andnurses have been trained to think that cost is not part of quality, that improving quality

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requires adding resources. As an example, Caldwell cites a California law thatmandates the number of patients allowable per nurse.

The place of savings in improvement initiatives, then, is yet another way in whichhealthcare differs from other industries. Manufacturers openly discuss cost as a qualitycharacteristic, but healthcare defines quality by the amount of resources applied.Concepts like savings, waste, and even errors and defects, says Caldwell, don’t enterinto the typical healthcare discussion of quality.

Changing the Terms of Healthcare Quality

Only senior leaders are in the position to change the definition of quality in theirorganizations. Leaders who do accept active responsibility for Lean-Six Sigma will findthe results worthwhile, in terms of both improved patient care and dollar savings.

Caldwell describes results he has witnessed at three hospitals:

• Miami Baptist Hospital achieved a 20% improvement in patient care throughputthrough Lean and Six Sigma approaches.

• Morton Plant Hospital in Clearwater, Florida, achieved a three-year Magic Momentof 26% improvement in ED length of stay, capturing over $5 million in cost of quality.

• West Jefferson Medical Center in New Orleans recovered over $5 million in lessthan six months by focusing on “In Quality” staffing and reduction of hospital-wideprocess waste.

Hospitals that are ready to consider quality in terms of efficiencies and dollar savings,as well as improvements in care, will find that the keys to achieving Lean-Six Sigmaresults like these are systemic, organization-wide improvements, accomplished throughsenior leadership involvement.

About Chip Caldwell

Chip Caldwell, specializing in strategic deployment of Lean-Six Sigma focusing on financialimprovement and throughput optimization, is the president of Chip Caldwell & Associates, and isthe Northern Florida Regent of the American College of Healthcare Executives. He alsoconducts the senior leader Lean-Six Sigma course for the American College of HealthcareExecutives and the American Society for Quality. He was the healthcare representative on theU.S. Quality Council in 1999-2000 and was formerly Health Industry Executive of Juran Institute.Caldwell previously served as president of the HCA Atlanta health system, an eight hospitalnetwork with fifteen owned family practice centers and over 250 contracted physicians. He alsoserved as president/CEO of HCA West Paces Medical Center in Atlanta from 1986 through1993.

A sample chapter from Chip Caldwell, Jim Brexler, and Tom Gillem’s recent book, Lean-SixSigma for Healthcare: A Senior Leader Guide to Improving Cost and Throughput , is availablefrom ASQ Quality Press.

Copyright © 2005 American Society for Quality. All rights reserved.