Quality Digest/March 2004 31

I n 2001, Heritage Valley Health System began to lookbeyond traditional health care process improvement tech-niques to offset the issues facing it and many other health

care organizations. Some of these issues were patient care andsatisfaction, finance, staff retention and recruitment, and collaboration with physicians on clinical initiatives.

Two improvement methodologies, the Toyota ProductionSystem and Six Sigma, were reviewed and highly regarded by thestaff, but the HVHS operations team ultimately decided todevelop a Six Sigma program. The decision was made followinglectures and demonstrations by TPS facilitators and facilitatorsfrom Air Academy Associates, the firm with which HVHS part-nered to roll out Six Sigma.

The most critical question facing the organization was, “Howcan an improvement methodology traditionally linked to manu-facturing apply to health care?” A related and frequently voicedconcern was, “How can we learn from Six Sigma experts whomight not understand patient care?”

Because Six Sigma is generally associated with manufactur-ing, there was concern that the deployment and implementationof the improvement methodology in a health care environmentwouldn’t work. To address this concern, HVHS educated its exec-utive leadership team on Six Sigma and piloted a few projectsprior to rolling it out across the system.

One Black Belt team was charged with evaluating the patientadmission process to observation or inpatient status. Within onemonth, the admissions process improvement team identifiedmultiple sources of lost revenue based on how patients were being

classified upon admission. More than $1 million in revenue wascaptured, and many internal processes were improved as a resultof this first project. The effort, from the initial project meeting tofinal staff education and process change, took seven months.

The second project involved a study of operating room utilization. A team of four, meeting once a week for severalmonths, identified that use of the organization’s ambulatory surgery center would improve by transferring typical outpatientsurgeries (e.g., for ear, nose, throat and minor orthopedic prob-lems, and cataracts) from HVHS’s operating room. The extracapacity generated for the hospital operating room was then filledwith inpatient-type surgeries, where the revenue covered over-head cost. An additional outcome from this project included aredesigned urology room, which helped the hospital avoid tandem scheduling of an additional room in case more extensiveintervention was required.

The positive results of these short-term projects provided theproof the organization needed to understand that Six Sigmacould indeed be applied to health care situations.

The next step was to train all leaders to the Champion level.During this training, HVHS’s senior management team spent threedays familiarizing themselves with the Six Sigma methodologyand rollout strategy. Practical examples and actual processimprovement experiments demonstrated Six Sigma’s effective-ness and emphasized the critical factors that must be controlledin order to successfully implement it. HVHS leaders developeda better understanding of Six Sigma methodology and theorganization’s multiyear plan to use the methodology to improve

by Richard Beaver

32 Quality Digest/March 2004 Write in RS No. 36 or visit www.qualitydigest.com

all aspects of its operation. Championswere taught to identify projects, selectBlack Belt candidates and then supportthem through all project phases.

Failure mode and effects analysis wasa key problem-identification and rankingtechnique the Champions used to developa project list. Potential projects were iden-tified and then ranked using five strategicimperatives: human resources, informationtechnology, finance, quality and marketgrowth, and expansion. At HVHS, qualitycomprises customer satisfaction, patient

and employee safety, and clinical out-comes. All efforts at HVHS are linked toand support one or more of these strategicimperatives.

One critical issue that surfaced wasthat not all leaders participated in devel-oping the original project or selectingBlack Belt candidates. At the start, HVHSdidn’t have a mechanism in place thatheld leaders accountable for their partici-pation, and this was desperately needed.However, the results garnered from lead-ers who fully participated in the original

effort helped identify key opportunitiesfor improvement and also provided nom-inations of those who became HVHS’sfirst Black Belt candidates. The organi-zation moved forward with the first waveof training and fixed the accountabilityissue before rolling out its second wave of training.

In August 2002, eight months after the decision to pursue Six Sigma, 22employees were sent off campus for train-ing. In concert with this effort, two half-day Six Sigma education sessions wereprovided to the board of directors andphysician leaders. The idea to includephysician leadership and board memberspaid significant dividends, as evidenced byprogress reports on Six Sigma implemen-tation throughout the following year.

Another important discovery from thefirst year was that students who were giventwo weeks of training (Black Belts typi-cally receive more) could make significantimprovements on most projects. Define-measure-analyze-improve-control tech-niques, when taught with project examples,provided a powerful toolset to achieve

About Heritage Valley Health System

H eritage Valley Health System, formed in 1996, is a community-based health care sys-

tem located in Western Pennsylvania. It encompasses The Medical Center in 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. It

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. HVHS is in partnership with more than 500 physicians.

The organization’s mission is to improve the health and well-being of all the

communities it serves.

33

gains in all areas of focus. The firsttwo weeks of the HVHS program aredesigned to cover all five phases ofthe DMAIC methodology. The firstweek provides the basic tools neededto identify issues, gather datathrough the measure phase and ana-lyze them for potential root causes ofprocess performance problems.

The second week—which occursafter a five-week period during whichstudents apply DMAIC methods totheir projects—includes the improve-ment phase as well as understandingproject management and how to sus-tain the gains received from theirefforts. Additional training, includingdesign of experiments and moreadvanced knowledge-gaining tools,were given to those who showed a strong interest and capability toprogress to the next level of processunderstanding.

Although it’s difficult to assign trained Black Belt candidatesto their projects full-time, the dividends gained from full-timeactivity far exceed the returns from part-time efforts. HVHS useda mix of part-time and full-time Six Sigma practitioners and foundthat worked well. Full-time allotment to project work resulted inrapid project completion, although several projects were com-pleted fairly rapidly by part-time students. However, these stu-dents often encountered conflicts in managing both a project andtheir normal work duties. Several part-time projects laggedbehind the six-month completion target and tended to lose steam.Despite the issues with longer project lead time, substantialproject gains were identified on 86 percent (19 out of 22) of thetraining projects undertaken by the first wave of students.

At HVHS, a trained Six Sigma candidate doesn’t receive Black Belt designation until the candidate and Champion can demonstrate a sustained gain from a project over a six- to 12-month period. The philosophy is that if the team can show sustained gains over this period, the process change is more likely to stick and become part of normal practice.

The next phase of work involved physicians. A few clinical-based projects, although they delivered excellent detail on theissues surrounding a specific diagnosis, weren’t gaining accept-ance throughout the system. Using ideas from the chief medicalofficer and again partnering with Air Academy Associates,HVHS provided a four-hour Six Sigma Continuing MedicalEducation class for physicians. Physicians commented that theSix Sigma methodology was easy to understand, and they likedthe technical, measurement-based philosophy.

As an outcome of this class, HVHS requested physicians topartner with project leaders either in a mentor/advisor role or,if they were willing, in a project leadership role. Today everyclinical project has a physician mentor or leader. The physicianis the key contact to the medical staff and presents findings at a peer level. Gains from this process are apparent in HVHS’s open-heart and cataract surgery projects, and results

Write in RS No. 29 or visit www.qualitydigest.com

Substantial

project

gains were

identified on

86 percent

(19 out of 22)

of the training

projects

undertaken

by the first

wave of

students

Substantial

project

gains were

identified on

86 percent

(19 out of 22)

of the training

projects

undertaken

by the first

wave of

students

34 Write in RS No. 37 or visit www.qualitydigest.com

are pending in heart failure, pneumoniaand chronic obstructive pulmonary dis-ease projects.

HVHS’s overall objective is to developSix Sigma as a “pull process.” With pre-vious endeavors, all employees weretrained in a given technique, but manybecame disheartened by the process ifthey weren’t given a chance to work onimprovement projects. Six Sigma is

becoming ingrained as it grows from shar-ing success stories. When a student closesa project, poster presentations are made,information about the project is sharedduring hospital week celebrations, andformal recognitions are planned. As otheremployees see and hear of this work, par-ticipation grows. A pull process is betterthan pushing new methods at employees,and there’s no better way to derive this pull

than by sharing information about quicklyobtained successes.

The cost of HVHS’s first year of train-ing was $123,000, including only externalcosts for educators, supplies, softwareand training facilities. Some of the edu-cation was developed and provided inter-nally. Student training time isn’t includedin this number. Returns from the firstyear’s effort far surpassed training cost interms of financial gains, process improve-ments, and gains in customer satisfactionand employee morale. Gains are talliedand reported to the organization and boardof directors.

Because of the results from the firstyear, the organization has decided toexpand its efforts by partnering with otherhospitals, increasing the number of proj-ects and students selected for the secondwave of training, and adding full-timestaff as project leaders.

Health care workers desire trainingrelated directly to issues that matter tothem. It’s imperative to include healthcare project successes during Black Belttraining and allow Black Belts to presenttheir projects and results at subsequenttraining courses. Establishing the organi-zational plan and communicating it duringChampion training is key to a successfuljourney toward Six Sigma acceptance andimplementation.

About the authorRichard Beaver is vice president of

quality for Heritage Valley Health Sys-tem. He has served as the leader of oper-ational excellence and quality for NovaChemicals Inc. and led operations, man-ufacturing, engineering and maintenanceat Sony Electronics Inc. He’s also com-pleted leadership training at the Center forCreative Leadership and obtained SixSigma Black Belt status at Sony and NovaChemicals under the curriculum and men-toring of Air Academy Associates. Hewould like your comments regarding thisarticle, e-mail him at rbeaver@hvhs.org orcall him at (412) 302-9900.

CommentsQuality Digest highly values feedback from

its readers. Please e-mail your comments

to comments@qualitydigest.com. qd