34 SEPTEMBER•OCTOBER 2003 THE PHYSICIANEXECUTIVE

• Physicians may believe significant change is unlikely,that hospital managers are insensitive to the constraintson their time and that the only important goal is tosave money.

• Management often feels that physicians veto initiativeswithout being involved, that they can circumvent institutional procedures to get what they want and thatthey are generally uninvolved unless an issue directlyaffects their practice.

• There is a sense that physicians undervalue the effortsof hospital managers and that there is no such thing asmedical staff consensus.

Developing supporters from skeptics

The application of the Six Sigma performanceimprovement methodology can help bridge the chasmbetween the medical staff and management of a hospital.

Since it is highly quantitative, physicians find SixSigma attractive and can appreciate the nuances of sam-pling, hypothesis testing and statistical relationships. Thestructured phases allow physicians to efficiently monitorthe progress of a particular project.

Six Sigma projects are based on solid data that is care-fully validated for accuracy. Such validation is necessary forphysicians who are trained to be critical of the validity andreliability of data. They regularly evaluate clinical informa-tion in a precise manner, so inaccurate information destroysthe credibility of improvement efforts.

Conversely, when data stands up to vigorous challenges by physicians, they become interested inunderstanding the data and its implications.

Finally, the Six Sigma methodology achieves lastingresults. It explicitly acknowledges that without continuousmonitoring and fundamental changes in systems andstructures, problems will always recur and improvementswill always deteriorate.

Six Sigma is a process improvement methodologythat is remarkably effective across many industries.

As hospitals face mounting regulatory burdens, callsfor improved quality and safety, serious budget chal-lenges and extraordinary capital requirements for infra-structure and new technology, many are implementing orconsidering Six Sigma to simultaneously improve clinicalquality and reduce operating costs.

When deploying Six Sigma, it’s important to havestrong buy-in and involvement of key stakeholders acrossthe organization. Without acceptance by stakeholders ofproposed improvement initiatives, failure is almost assured.

The physician relationship with hospitals is unique.Although physicians often are not employed by hospitals,they are critical drivers of hospital performance. Hospitalshave limited influence over physicians given their inde-pendent status, technical expertise, political influenceand, at times, different business objectives.

Physicians often complain about the difficulty ofmaking improvements in hospitals. They may be skepti-cal of management’s ability to deliver results, perceivemeetings as a waste of time and see process improve-ment initiatives as endless—or as “flavors of the month”that will quickly pass.

Moreover, physicians perceive hospital improvementefforts largely as a way to reduce staff and services, whilephysicians want improvements in clinical quality.

The physician relationship with hospitals is unique inanother way since physicians are simultaneously stake-holders and customers. They are stakeholders in that thequality of care they can provide is highly determined byhow the hospital functions. Through medical staff com-mittees, physicians greatly influence the operations of theorganization.

On the other hand, as customers, physicians evaluatethe hospital as a workplace and choose to practice inone system over another. When trying to enlist their support in change efforts, it is important to recognize thisdual nature and address their needs in both roles.

Both physicians and hospital staff can bring destructivepreconceptions with them when they try to collaborate onprocess improvement.

The Art and Science of Winning PhysicianSupport for Six Sigma ChangeBy Walter Ettinger, MD and Mark Van Kooy, MD

Active physician participation and acceptance of SixSigma is critical to successful implementation. Take alook at strategies and techniques that can help secure physician support for Six Sigma.

Six Sigma

IN THIS ARTICLE…

THE PHYSICIANEXECUTIVE SEPTEMBER•OCTOBER 2003 35

Physicians justifiably are skepti-cal of change initiatives that have notproduced sustained improvements.The latter is a recurrent problem inmany hospitals across the country.

Tools and techniques forphysician buy-in

Since physicians are likely tobe skeptical, how should they beintroduced to Six Sigma? Physiciansmay be customers, stakeholders,sponsors, team members, processowners or champions. It is impor-tant to be clear about the level ofparticipation needed and the rolephysicians should fill.

For example, it is usually unre-alistic to expect—and unnecessaryfor physicians to attend—weeklyteam meetings. Instead, determinewhat is needed from physicians upfront and how best to obtain it andget agreement on these points withphysicians. Sometimes the need issimply for physicians to refrainfrom active opposition.

Other situations may require adecision or specific technical infor-mation. Careful planning can leadto efficient use of physician timeand increase their support.

Six Sigma provides techniquesfor identifying the level of participa-tion required. Teams can use toolssuch as Stakeholder Analysis andARMI (Approver, Resource, Member,Interested Party analysis) to deter-mine the level of participation need-ed from physicians. Think creatively.

Consider convening a physi-cian advisory group that only meetswhen truly necessary. This groupmight meet at the beginning of aproject to understand the goals andvalidate the need for the effort.

Carefully explain and getagreement from the physicians as

to their role in the project, what isexpected of them and how commu-nication will be handled. Meetingsshould be scheduled on a regularbasis, but only truly as needed.

In the course of a fairly com-plex project at one institution thataddressed the safety and effective-ness of acute anticoagulation, onlythree 90-minute physician meetingswere required during a six-monthproject.

Even so, physicians were suffi-ciently involved to propose andactively support the requiredimprovements at the pharmacy andtherapeutics committee and themedical executive committee.

Consider “just-in-time” physi-cian involvement. Keep physiciansinformed about project progressand the active issues the team isconsidering. Team leaders might use

e-mail for updates and to share thestructured project documentationwith important stakeholder physi-cians, then bring their thoughts andreactions back to the team.

This approach to including thephysician perspective can keep theteam on track with the medical staff.

Winning the data game

The disciplined approach todata integrity and analysis that is

Tips for Gaining Physician Support

• Get agreement up front on the role of physi-cians and the process of how their input will begiven to the project

• Start with projects in which the processes arethe responsibility of the hospital—get results togain credibility

• Consider “just-in-time” physician involvement

• Use e-mail to maintain communication, provide updates and gain physicianperspective

• Present “bulletproof” data when asking physicians to change their behavior

• During projects seek early wins for medical staff

• Work supportively with outlier physicians

• Celebrate success and recognize physician contribution

• Point out that improved financial performance results in more money fornew equipment and technology

Measurement system accuracy is central to a Six Sigma project.

36 SEPTEMBER•OCTOBER 2003 THE PHYSICIANEXECUTIVE

imbedded in the Six Sigma processhelps win physician support.Management may anticipate a skep-tical physician response to theirdata with good reason.

Physicians are adept at identify-ing flaws in data collection andanalysis and have been trainedthroughout their careers to questionthe data presented to them. Patientsgo through repeated histories whenmultiple physicians are on a case

because the gold standard forphysician data is the data they col-lect themselves. They are trained todoubt even information gathered by trusted colleagues until it is confirmed by their own exam.

Physicians keep current byreading peer-reviewed articles.Remember, peer-reviewed meanscolleagues examine the data andconclusions presented, then workdiligently to find flaws in the data.

Only data and conclusions thatwithstand intense examination standas new science. So it is not surpris-ing that physicians will also doubtthe data presented by hospital staff.

Six Sigma works very well inthis environment. Measurement system accuracy is central to a SixSigma project. Physicians are veryimpressed with rigorous confirma-tion of measurement system accura-cy and the statistical projection of

What is Six Sigma?

Sigma is the Greek letter representing standard devia-tion or the amount of variation within a givenprocess. The higher the Sigma level, the lower thenumber of defects. Achieving a Six Sigma level ofquality equates to a mere 3.4 defects out of one mil-lion opportunities, or nearly error-free performance.

Sigma Defects Per Million (DPMO) Opportunities

2. 308,537

3. 66,807

4. 6,210

5. 233

6. 3.4

Six Sigma is similar to other programs such asTQM (Total Quality Management) and CQI(Continuous Quality Improvement) but with severalkey differences:

Six Sigma focuses on process improvement thatresults in significant and quantitative change in impor-tant outcomes.

1. Careful analysis of customer expectations drives allimprovement efforts and targets. In health care thisusually means patients, but often includes physicians.

2. Six Sigma recognizes that the average performance ofa process is only part of what customers experience—variation is also critical. It is important to reduce varia-tion so that the customer’s expectations are alwaysmet. Indeed, the goal of Six Sigma is to reduce failuresto a level of nearly 3 in 1,000,000.

3. Six Sigma assures long-term, sustained improvementby mobilizing commitment from key stakeholders byusing continuous monitoring and by making changesin systems and structures so short-term gains aremaintained.

4. The tools and structure within Six Sigma are designedto organize problem-solving efforts and achieve meas-urable business results. The goal is to simultaneouslyreduce costs while improving quality and customersatisfaction.

improving the physician experienceto increase physician buy-in.

At some point, many teamsneed to ask physicians to changetheir behavior to improve safety orreduce unnecessary resource utiliza-tion. This is the time to present

bulletproof data demonstrating theimpact of physician performance.Show what has already improvedand what can only be achieved ifphysicians will change.

Data that illustrates process varia-tion is particularly useful at this pointand can highlight outlier physicianbehavior. Good data can generatecreative tension within the medicalstaff. Consider supportively workingwith outlier physicians to help themunderstand the information and thepotential benefits to them and theirpatients if they change.

Try to achieve some quick winsfor the medical staff. Six Sigma proj-ects may take four to six months toget results. During the project, more focused issues often become

1. Laboratory and radiology resultsreadily available when the physicians made rounds

2. Nurses stations standardized andproperly stocked with commonlyused forms

We fixed these mundane prob-lems and built trust to tackle moredifficult issues. This step of “gettingsomething done” buys credibilitywith physicians.

Next, work with the physiciansto see what areas of shared respon-sibility can be improved. Finally,when the important remainingissues depend on changing physi-cian behavior for improvement,seek changes from the medical staff.

Encourage physician complaintsabout hospital systems, especiallyearly on in deploying Six Sigma.This is an important source of feed-back. A willingness to address theseissues may surprise physicians andencourage them to engage with theteams. Place a high priority on

• Projects carefully selected to focuson customer requirements and CTQs(critical to quality elements)

• Targets variation within processes

• Highly structured, phased approachbuilt around rigorous metrics andstatistical analysis

• Incorporates Control Phase and toolssuch as “dashboards” to maintainimprovement long-term

• Projects usually driven by the qualitydepartment and often not alignedwith organizational objectives

• Looks primarily at averages

• Some familiar statistical tools, butapplied with less rigor or structure

• No built-in mechanism for assuringthat changes don’t unravel over time

THE PHYSICIANEXECUTIVE SEPTEMBER•OCTOBER 2003 37

required sample size that are integral to Six Sigma.

In our experience, physiciansrespond to Six Sigma data in threesteps.

1. They challenge the data asusual.

2. When their initial objections areaddressed, they take a morefocused approach to questioningthe quality of the data.

3. When the data stands up again,the physicians sit up a bit anddust off their methodologicaltraining. They ask a few morepointed questions about themethodology, see that it issound and then a transformationtakes place.

Often, this will be the first timethey’re seeing credible informationabout how an important process istruly performing. At this point youhave their attention and often theirsupport.

A planned approach

So, how to get started introduc-ing Six Sigma to the medical staff?

First, focus on processes in clini-cal care that the hospital system issolely responsible for and that areimportant to physicians. Ask physi-cians about the day-to-day issues thatimpede their efficiency.

Only involve physicians whoinsist on participating. Improvethese areas first and be prepared toshow physicians how the processhas changed.

For example, in one of ourinstitutions two issues were identi-fied that were sore points for med-ical staff:

Six Sigma projects may take four tosix months to get results

Six Sigma Standard Quality Initiatives

38 SEPTEMBER•OCTOBER 2003 THE PHYSICIANEXECUTIVE

evident. Rapid cycle problem solv-ing can deliver meaningful improve-ments in a matter of days to weeks.Quick, significant improvementsthat make things better will getphysician attention.

In the end, achieving meaning-ful results will deliver physiciansupport. Be sure to communicatesuccesses to the physicians.

A recent project resulted in adramatic increase in billing and col-lection of carve-out items in theoperating rooms at our system.Revenue resulting from this projectis being driven directly back intocapital projects that the physiciansare very interested in. These con-nections are very clearly drawn forour medical staff.

One of the most important suc-cess factors in Six Sigma is celebrat-ing successes. Even without regularmeeting attendance, physicians arecritical to the success of many proj-ects and should be visibly recog-nized for their contributions.

Noting changes in longstandingclinical practices, outlier behaviors,improved billing practice, better on-time starts in the ORs and contribu-tions of knowledge and experienceare all important ways to acknowl-edge the critical role physicians playin supporting Six Sigma.

Six Sigma can help hospitalleaders forge common goals andtrust with physicians. Lastingimprovement from hospital/physi-cian collaboration is important forthe productive long-term relation-ship that both parties need to provide outstanding patient care.

Walter H.Ettinger, MD,MBA, is vice presi-

dent of medical affairs and medicaleducation at Lenox Hill Hospital inNew York City. He can be reached byphone at 212-434-3979 or by e-mailat WEttinger@lenoxhill.net.

Mark Van Kooy,MD, is the SixSigma Master

Black Belt at Virtua Health inMarlton, N.J. He can be reached byphone at 856-355-0075 or by e-mailat mvankooy@virtua.org.