Leadership: First, Get an Expert to Start ED Overhaul

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A California hospital started with a Six Sigma expert, who then learned about healthcare and, with fresh eyes, turned around the ED.

Let's throw a pair of numbers out there: 26% and 3%. Those are the percentages for emergency department diversion rates Providence St. Joseph Medical Center, Burbank, CA, saw prior to and after targeting the topic for improvement with Six Sigma.

Since introducing Six Sigma in its Southern California medical centers, Providence California has seen across-the-board improvements in clinical outcomes, care, customer relations, and finance.

The ED became the organization's first target for improvement. Three areas were highlighted: ambulance diversion rates, number of patients who left without seeing a physician, and overall length of stay in the department.

"The spark was started at the system level," says Arnold R. Schaffer, vice president and chief executive with Providence California, part of Providence Health & Services.

Like all organizations, Schaffer says, Providence was searching for ways to strive toward excellence in quality. It began a process of exposing senior and upper management to different models for process improvement in other industries.

"We realized it's really improbable to take someone else's model and [successfully implement] it in your organization," says Schaffer. "You've got to find your own way. We in California immediately went a different route."

This meant the first step to implementing Six Sigma was bringing in fresh eyes—the system brought in a high-level Six Sigma Black Belt and taught the person about healthcare rather than teaching a healthcare expert about Six Sigma.

"Then," says Schaffer, "we made a major commitment—we knew this wasn't flavor of the month. We funded it aggressively. It sometimes appeared we overfunded it."

But, Schaffer noted, push doesn't work well in management—the trick is to get management buy-in so pull happens instead.

"After about 18 or 24 months, as [Six Sigma] built up slowly, the results were so impressive that the organization started to pull," says Schaffer.

Allocating resources
The organization is up to 10 full-time black belts, 32 change facilitators, one master black belt, and two master change facilitators.

"We use them between five hospitals and all of our support services," says Schaffer. "Rather than strictly embedding them in single hospitals—which we had also done for a while—allocation of resources and priority of setting is done on a regional setting."

Despite these impressive numbers, there is still room for expansion—and Schaffer is all for it.

"The return on investment is so great that I'm happy to get more," says Schaffer. "It's not one of those things to keep resources down. Try to get your organization to pull more resources. The more they pull the more you get."

So how big was that return on investment? How about $11 million in savings?

And it's not just about the money, says Schaffer.

"Take out the salaries of those people involved and you have a tremendous financial pickup. A lot of the work that they do, though, we don't measure in financial terms," says Schaffer. "There are all sorts of things you could put money to, but it gets too squishy. All numbers that come out for our Lean Six Sigma program are validated by our CFOs, and CFOs are not squishy."

Immediate results
Providence operates an independent blood center, with several blood mobiles on the road.

"We increased our availability—not just volumes of blood, because we had people backed up wanting to donate, but prior to Lean Six Sigma we were only able to capture 30 units a day per vehicle," says Schaffer. After Six Sigma? That number jumped to 75 units a day per vehicle.

Successes occurred inside the walls as well.

"The one that really touches me the most directly, that we're the most thrilled about: We have a hospital in Burbank whose ED was overwhelmed at all times," says Schaffer.

The ED had a diversion rate between 25% and 30%. It was this facility that saw its diversion rate drop down to 3%.

"It was a total redesign, but not physical," says Schaffer.

EDs have a lot of similarities across the country; it has been said that EDs are 80% the same regardless of facility. ("That 20% is a big difference," notes Schaffer.) Most ED staff "grew up" in another ED. They've worked in the same environment most of their lives. This means you've got to use a zero-base process redesign.

"The black belts help the team to do this," says Schaffer. "They see no boundaries."

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